Charting A New Course: EMS Education Standards Part 1

     Anyone who has been an EMS educator for more than 15 years will recall the transition from EMT to EMT-B. Developed in relative secrecy, the 1994 release of the EMT-B curriculum brought what appeared to be unprecedented changes to the terminology, scope and practice of EMS. There was an initial wave of anger and disbelief--a sense of loss--in a curriculum many believed "dumbed down" EMS education. Subsequently, curricula were released for all remaining levels of EMS training, ending with EMT-Intermediate in 1999.

     If the 1990s brought unprecedented change to EMS education, it was only unprecedented until the release of the National EMS Education Standards in 2009. The education standards process, which was open for comment from the EMS community from beginning to end and uses a non-prescriptive approach, could be considered almost the opposite of the 1994 curriculum release. Coming full circle, the new education standards bring us back to many 1985 terms and concepts, including primary and secondary assessments, and drop "Basic" from the EMT certification level.

     This series of three articles will introduce educators to the education standards, detail some of the changes in concept and content, and interview educators and administrators about how these changes will be implemented.

     THE PROCESS

     The education standards are one step in a long process that began with the 1993 EMS Education and Practice Blueprint to help define EMS providers and practice on a national level. In 1996, the EMS Agenda for the Future was developed, followed in 1998 by the EMS Education Agenda for the Future: A Systems Approach. The education agenda began a long-term vision in which the education standards play a central role. In the document, the following processes were recommended:

• National EMS Core Content: A list of skills and knowledge necessary for the practice of EMS. This was completed in 2005.
• National EMS Scope of Practice: This 2006 document distributes material identified in the core content document among four levels of EMS provider: Emergency Medical Responder, Emergency Medical Technician, Advanced EMT and Paramedic. The scope of practice identifies minimum knowledge and skills for providers at each level.
• National EMS Educations Standards: released in 2009.
• National EMS Certification: future release.

•      National EMS Education Program Accreditation: future release.

       EMS stakeholders who participated in developing the Education Agenda believed that:

• An established national EMS education system would align EMS with other health professions and enhance the professional credibility of EMS practitioners.
• National EMS education standards should replace the National Standard Curricula (NSC) in order to increase instructor flexibility and provide a greater ability to adapt to local needs and resources.
• Education standards would permit introduction of new technologies and evidence-based medicine without requiring a full revision of the entire education program.
• The Education Agenda would assist states in standardizing provider levels across the nation, affording ease of reciprocity and greater opportunities for career growth in EMS.
• EMS scope of practice should be based on evidence, including practice analysis and research, of what does and doesn't work in the field.
• National EMS certification standardizes verification of entry-level competency and supports EMS career mobility.

     Figure 1 shows the interrelation of components mapped in the EMS Education Agenda for the Future.

     It was also determined that the education standards, when released, should use a non-prescriptive approach. Unlike the voluminous 1994 curriculum, which contained a detailed declarative section for each lesson, the 2009 standards are designed to be a "living, breathing" document designed to weather changes in medicine and technology that quickly outdate prior curricula.

     CURRICULA VS. STANDARDS: A SIDE-BY-SIDE COMPARISON

     The fundamental difference between the education standards and prior curricula is the non-prescriptive approach to the former's presentation. This shift presents both theoretical and functional issues to implementation.

     If you place the two documents side by side, it's easy to see that the 1998 Paramedic National Standard Curriculum stretches the capacity of a 4-inch, three-ring binder, while the new education standards for all levels, including acknowledgments and a historical perspective, come in at only 80 pages.

     Prior curricula had detailed declarative information—lesson plans, if you will—that provided detailed procedural and content guidance. While the content guidance was helpful in implementing the curricula at the outset, and helped create some uniformity of educational materials, it quickly became outdated. The curriculum being used for EMS education in 2009 contains clinical recommendations that are between 10-15 years old. While it wouldn't be acceptable for a clinician to rely on material this dated, it is the position in which we found ourselves in EMS.

     For a quick look at what has changed over the years, consider that the 1994 EMT curriculum recommends restraining psychiatric patients face-down, barely acknowledges pulse oximetry (with no concept of carbon monoxide oximetry being done in the field), and doesn't consider epinephrine auto-injectors for use on ambulances, not to mention the number of changes in CPR that have come and gone in those years.

     A LIVING, BREATHING DOCUMENT

     The new education standards have been described as a living, breathing document that avoids the voluminous declarative detail found in prior curricula. This will prevent the material from becoming outdated and require less frequent revision.

     Another benefit is that the education standards more closely match the materials used in educating other allied health professionals and helps move EMS closer to a much-desired "professional" status.

     Although most people in EMS recognize the necessity for this type of document to guide EMS education into the future, the transition is not without issue or concern. In a young profession with a wide variety of EMS education and delivery methods (paid and volunteer, community-based, certificate and degree education programs), many are concerned over issues such as:

• How will a course taught in one state be similar to one in another state without more detailed content description?
• How will a national examination apply to providers trained in different areas?
• Will one textbook present the standards dramatically differently than another?
• Will all states adopt the education standards? How will differences in scope of practice and local/state protocols be affected?
• Why don't the standards specify how many hours a course should be?

     These questions have been posed to national EMS experts and some of those involved in developing the education standards. Next month's article will contain their detailed responses.

     For now, it seems safe to say that, with an outdated curriculum, many programs have already evolved into teaching current science. In fact, one of the biggest benefits—both to the standards and EMS as a profession—may be that we are able to use current research as the barometer for what should and shouldn't be taught in an EMS classroom. The length and scope of EMS classes vary dramatically around the country, yet many states use the same National Registry examination. This indicates that we are able to test accurately despite regional and state differences.

     Finally, a set of instructional guidelines (IGs) have been developed for some content guidance during implementation of the standards. The IGs provide conceptual rather than clinical or definitive guidance to course content.

     In addition to the miniscule footprint on your desk compared to prior curricula, the education standards have a different layout and structure for the four components (see Figure 2).

1. Competency: This represents the minimum competency required for entry-level personnel at each licensure level.
2. Knowledge Required to Achieve Competency: Represents an elaboration of the knowledge within each competency (when appropriate) that entry-level personnel must master to achieve competency.
3. Clinical Behaviors/Judgments: Describes the clinical behaviors and judgments essential for entry-level EMS personnel at each licensure level.
4. Educational Infrastructure: This section describes the support standards necessary for conducting EMS training programs at each licensure level.

     CONTENT DIFFERENCES

     This article is an introduction to the new EMS education standards—one of the most significant changes in EMS and EMS education for decades, both in scope and relevance to EMS professionalism. It is widely believed that the standards for EMT have undergone the most significant changes. It is estimated that the EMT course will take approximately 140-170 hours to complete. The difference lies not in skills, but in a significant philosophy shift.

     While the 1994 EMT-B curriculum strayed from pathophysiology and material that was not considered necessary to care for general conditions, the education standards take an opposite approach. With the philosophy that having a deeper understanding of underlying principles will ultimately enhance assessment and care, the standards include pathophysiology at the EMT level. The area on respiratory anatomy and physiology includes a detailed discussion of respiration at the cellular level and how that relates to the body as a whole.

     While these differences will add student hours to programs not already teaching these concepts, educators will also feel the impact of the expanded content. Some educators may not have a significant grasp of physiologic and pathophysiologic principles to teach the EMT course, or will require significant preparation to do so. At more than one public meeting it was pointed out that the depth of content in the new education standards "would leave some bodies by the side of the road."

To download the education standards, go to www.ems.gov.

Daniel Limmer, AS, EMT-P, has been involved in EMS for 31 years. He is active as a paramedic with Kennebunk Fire-Rescue in Kennebunk, ME. A passionate educator, Dan teaches basic, advanced and continuing education EMS courses throughout Maine.