All US states and territories require that providers staffing EMS vehicles have successfully completed a program of initial training and passed an examination process. These providers are also required to complete continuing education in order to continue practice. EMS medical directors are responsible for the oversight of these education programs. Additionally, they should continually evaluate the actual clinical performance of their providers and, through their quality improvement process, implement an ongoing education program designed to continually improve provider practice. EMS education in the United States, although guided and supported by national guidelines and curricula, is regulated at the state level. As a result, the specific provider levels of training and the corresponding educational requirements vary from state to state. Fortunately, there are generalizations about provider education that can be made about the overall education and training processes and requirements.

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  Describe the national basis for the education of prehospital providers.

  
  
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  Describe the levels of prehospital providers and typical training requirements at each level.

  
  
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  Describe the types of educational organizations providing EMS education and the role of accreditation in preparing candidates for national EMS certification.

  
  
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  Detail the use of high-fidelity simulation.

  
  
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  Discuss the use of distance learning, including advanced self-study and Web-based education.

  
  
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  Detail the development of a field preceptor program and criteria for clearing a provider for independent practice.

  
  
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  Define remediation and discuss its use in educational programs and for providers identified during CQI as having additional education needs.

  
  
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  Contrast National Registry certification to state-specific EMS provider certification.

  
  
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  Discuss continuing education requirements and recertification pathways.

The most common levels of training include emergency medical technician (EMT) basic, EMT-intermediate, and paramedic. Many states also include some type of formal first responder training level. This training is provided by a wide variety of institutions ranging from formal degree programs in traditional educational institutions such as colleges and universities to system-based training programs. In all states, this training is, at least loosely, based on national standards, as is the standardized examinations administered either at the state level or by a national organization (new national standard levels: EMR, EMT, AEMT, paramedic).

Many EMS systems have advanced evaluation tools that medical directors can use to measure actual clinical performance. These tools are typically used by field training officers (FTOs)/preceptors to determine and institute “stretcher-side” training aimed at continuous teaching. Additionally, EMS educators and medical directors utilize a variety of mechanisms, including simulations and distance learning methodologies, to carry out their educational goals.

As with all of EMS, the medical director bears ultimate responsibility for ensuring that the education provided at both the initial and continuing levels is clinically and scientifically appropriate and up to date.

Authority for defining and regulating EMS provider education, certification, and licensure in the United States is held by each individual state. While the federal government has a role in providing technical support, it is the states that ultimately define the education required to become an EMS provider. As a result, there has historically been a large disparity between provider levels among the states, a situation that has made providing for interstate reciprocity a difficult task. Partly in recognition of this, and in response to the education vision outlined in the 1996 EMS Agenda for the Future document, the National Highway Traffic Safety Administration published the EMS Education Agenda for the Future in 2000. This document is becoming the foundation for the state’s regulation of EMS education. It describes a national EMS education system comprising five related components as depicted in Figure 7-1.

The National EMS Core Content is analogous to the Model of the Clinical Practice of Emergency Medicine (formerly the “Core Content”) upon which emergency medicine residency and board certification is based. Because the Core Content defines the medical knowledge required for the profession, physician organizations such as the National Association of EMS Physicians (NAEMSP) will be primarily responsible for maintenance and revision of this document. The EMS Core Content defines the knowledge and skills required of EMS providers but does not dictate the differences between levels of providers. The distinction of what is required of each level of provider, that is, the definitions of provider levels, is described in the National EMS Scope of Practice Model. The knowledge and skills, thus divided up among provider levels, is broken down into learning objectives in the National EMS Education Standards. These Education Standards are meant to replace the prior National Standard Curriculum for each provider level. The standards are what EMS education programs and publishers will use to create lesson plans and textbooks.

Additionally, the standards will be used as the basis for what will be on the standardized examinations used for National EMS Testing. Finally, the EMS Education Agenda recommends that, as a requirement to sit for the national examination, a candidate must have completed an education program that has been accredited by a national accrediting organization.

Currently, the organization that is developing and offering national examinations is the National Registry of EMTs (NREMT). Likewise, the Committee on Accreditation of Educational Programs for the EMS Professions (CoAEMSP) is the organization that ensures an accredited education program has demonstrated that their curriculum adequately covers the material described in the EMS standards.

Few things in EMS have given rise to more angst than the terms certification and licensing. Unfortunately, these terms are frequently used imprecisely, interchangeably, or incorrectly. It is important to review these terms in order to avoid this angst and understand how these different components overlap. While there may be some States that have specifically defined these terms in different ways, we will describe them here in the context used by national documents and organizations to illustrate the concepts involved. The Venn diagram in Figure 7-2 helps define the relationship between these domains.

Education refers to the knowledge and skills gained by the provider during his or her initial preparation for practice as well as his or her continuing education. Certification is provided by a national testing organization, currently the NREMT, attesting that the provider has demonstrated competence, through written and skills testing, as a “minimally competent” provider at a given level, that is, paramedic. Licensure is granted by each state to those individuals who have been certified by the testing agency. Finally, and most importantly at a system level, a licensed provider may only practice if credentialed by the local EMS medical director. In some systems, credentialing may also be referred to as authorization to practice.

The National EMS Scope of Practice document describes the four levels of EMS provider: emergency medical responder, EMT, advanced emergency medical technician (AEMT), and paramedic. Emergency medical responders have been called first responders in the past as have AEMTs been referred to with names such as EMT-intermediate and EMT-special skills. Training at each level includes didactic instruction (traditional classroom lectures), procedure labs where psychomotor skills are taught and practiced, hospital-based clinical rotations, and field-based clinical rotations. Some programs will also require a field preceptorship that is roughly analogous to a physician’s internship. It is done after the student has completed all other program requirements and is focused on integration of the knowledge and skills. It is typically completed with the same field preceptor over the course of multiple shifts and, optimally, should be based on well-defined objectives with progressive clinical responsibilities ending with completely managing all aspects of the call as though they are no longer a student. Table 7-1 lists typical requirements for each provider level. While some states may require specific hours but the recommendations of the CoAEMSP is that requirements be based on achievement of specific objectives and demonstration of defined competencies rather than specific hours.

EMS education is provided in very diverse fashion throughout the country with sponsoring organizations ranging from local EMS systems/fire departments and private training programs to 4-year universities and medical schools. This diversity is probably most noticeable at the basic levels (EMR and EMT) and less so at the paramedic level where there has been some coalescence behind academic affiliations. Much of the nation’s paramedic education programs, and the vast majority of accredited programs, are now offered through community colleges and universities. The requirements for approval of a training program vary by level and from state to state. The specificity of these requirements also increases with provider level with the requirements at the paramedic level being more detailed than at the lower levels.

Accreditation is a widely accepted mechanism for ensuring that an educational program meets recognized standards in their educational processes. The agency recognized by the National Association of EMS State Officials (NAEMSO) to provide accreditation services is the Commission on Accreditation of Allied Health Education Programs (CAAHEP). CAAHEP is composed of multiple committees that specialize in the various allied health professions. CoAEMSP is the CAAHEP committee dedicated to EMS accreditation. NAEMSO, composed of state regulators, voted in 2010 to require CAAHEP accreditation in order to sit for the NREMT’s national EMS paramedic certification examination beginning January 1, 2013.¹ CoAEMSP only accredits paramedic level programs, although these programs frequently offer options to “test out” at lower levels such as EMT.

The process of becoming accredited involves the program completing a rigorous self-study that describes how it complies with the accreditation criteria or standards. These standards are based on accepted educational processes and supported by the EMS Education Standards as published by NHTSA. The program then develops a report based on this self-study and submits it to CoAEMSP, which then assigns a trained site visit team to come review the program in person. This team then prepares a report detailing, in objective terms, the program’s compliance with the standards. The CoAEMSP board will then review the site visit team’s report and make a recommendation to the full CAAHEP regarding accreditation. Ultimately, it is CAAHEP that issues the accreditation. The program must then submit ongoing progress reports to CoAEMSP and undergo periodic reaccreditation similar to the initial process.

While the initial education, certification, and licensing of a medic are clearly very important, it is but the beginning of a continuing process of evaluation, training, and reevaluation. The medical director is responsible for this process but will likely need the assistance of FTOs. While it would be ideal for the medical director himself to perform these evaluations, it often is not feasible in all systems. These FTOs are valued employees who have demonstrated superior clinical, teaching, and interpersonal communication skills and are specifically trained to evaluate medics using objective performance criteria. The FTO process is the most accurate means of evaluating a medic’s actual performance in a real-world environment. The criteria used should have several features: they should be specific, measurable, attainable, and tied to desired job-related competencies.