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Scope of Practice for Emergency Medical Service Providers

[47 Pa.B. 3291]
[Saturday, June 10, 2017]

 Under 35 Pa.C.S. §§ 8101—8157 (relating to Emergency Medical Services System Act) and the Depart- ment of Health's (Department) regulations in 28 Pa. Code §§ 1023.24(d)(1), 1023.25(d)(1), 1023.26(d)(1), 1023.27(d)(1), 1023.28(d), 1023.29(d) and 1023.30(e), the Department is publishing the scope of practice for emergency medical responders (EMR), emergency medical technicians (EMT), advanced emergency medical technicians (AEMT), paramedics, prehospital registered nurses (PHRN), prehospital physician extenders (PHPE) and prehospital physicians (PHP).

 Skills identified may be performed by an emergency medical service (EMS) provider at the provider's level of certification or registration only if the provider has successfully completed the approved education (cognitive, affective and psychomotor) on the specified skill, which includes training to perform the skill on adults, children and infants, as appropriate. EMRs, EMTs, AEMTs and Ps may only perform the skills identified, through either Statewide or other Department-approved protocols, or skills that may be ordered online by a medical command physician.

 As the following chart indicates, a PHRN, PHPE and PHP may perform all skills identified as within a paramedic's scope of practice. Each of these EMS providers may perform additional skills outlined as follows.

 A PHRN who is appropriately credentialed by the EMS agency medical director may perform other services authorized by The Professional Nursing Law (63 P.S. §§ 211—225.5) when authorized by a medical command physician through either online medical command or through the applicable Statewide or Department-approved EMS protocols.

 A PHPE who is appropriately credentialed by the EMS agency medical director may perform services within the scope of practice of a physician assistant under the Medical Practice Act of 1985 (63 P.S. §§ 422.1—422.51a) or the Osteopathic Medical Practice Act (63 P.S. §§ 271.1—271.18) when authorized by a medical command physician through either online medical command or through applicable Statewide or Department-approved EMS protocols. When a PHPE functions as an EMS provider, the physician supervision requirements applicable to a physician assistant under the Medical Practice Act of 1985 and the Osteopathic Medical Practice Act do not apply.

 A PHP who is appropriately credentialed by the EMS agency medical director may perform skills within a paramedic's scope of practice and other skills within the practice of medicine or osteopathic medicine. A PHP may not perform a skill that the PHP has not been educated and trained to perform.

 Under 28 Pa. Code § 1023.1(a)(1)(vi) and (vii) (relating to EMS agency medical director), the EMS agency medical director must make an initial assessment of each EMS provider at or above the AEMT level, and then within 12 months of each prior assessment, to determine whether the EMS provider has the knowledge and skills to competently perform the skills within the EMS provider's scope of practice, and a commitment to adequately perform other functions relevant to the EMS provider providing EMS at that level. EMS providers at or above the AEMT level may only perform skills that the EMS agency medical director has credentialed them to perform.

 The Department wishes to highlight the following change to the scope of practice for all EMS providers. Effective November 29, 2014, administration of Naloxone in intranasal or auto-injector form is approved for all levels of EMS providers and is listed under the ''Medications'' category of this notice. This change is under sections 13.7 and 13.8 of The Controlled Substance, Drug, Device and Cosmetic Act (35 P.S. §§ 780-113.7 and 780-113.8), which requires the Department by December 31, 2014, to amend the scope of practice for EMS providers to include the administration of Naloxone. Prior to this change, Naloxone was listed on the approved drug list only for ALS ambulance services and for advanced-level EMS providers. See 42 Pa.B. 4229 (July 7, 2012).

 Persons with a disability who require an alternate format of this notice (for example, large print, audiotape, Braille) should contact Richard Gibbons, Department of Health, Bureau of Emergency Medical Services, Room 606, Health and Welfare Building, 625 Forster Street, Harrisburg, PA 17120-0710, (717) 787-8740. Speech or hearing impaired persons may call by using V/TT (717) 783-6154 or the Pennsylvania AT&T Relay Service at (800) 654-5984 (TT).

Category Skill
EMR EMT AEMT P*
1 Airway/Ventilation/Oxygenation Airway—Nonsurgical Alternative/Rescue Airway—CombiTubeTM, iGel® Supraglottic, King LT-D AirwayTM or King LTS-D AirwayTM No No Yes Yes
2 Airway/Ventilation/Oxygenation Airway—Oropharyngeal (OPA) and Nasopharyngeal (NPA) Yes Yes Yes Yes
3 Airway/Ventilation/Oxygenation Airway—Pharyngeal tracheal lumen (PTL) No No No No
4 Airway/Ventilation/Oxygenation Bag-valve—ETT/Nonsurgical alternative airway ventilation Yes2 Yes2 Yes Yes
5 Airway/Ventilation/Oxygenation Bag-valve-ventilation—with in-line small-volume nebulizer No Yes2 Yes Yes
6 Airway/Ventilation/Oxygenation Bag-valve-mask (BVM) ventilation Yes Yes Yes Yes
7 Airway/Ventilation/Oxygenation Chest decompression—needle No No No Yes
8 Airway/Ventilation/Oxygenation Chest tube thoracostomy, monitoring of existing tube in a closed system (for example water seal or suction) No No No No
9 Airway/Ventilation/Oxygenation Chest tube thoracostomy, acute insertion No No No No
10 Airway/Ventilation/Oxygenation Continuous positive airway pressure (CPAP) No Yes1 Yes Yes
11 Airway/Ventilation/Oxygenation Biphasic positive airway pressure (BiPAP) for patients chronically on BiPAP for >48 hours No No No Yes
12 Airway/Ventilation/Oxygenation Biphasic positive airway pressure (BiPAP) for patients on BiPAP for <48 hours No No No No
13 Airway/Ventilation/Oxygenation Cricothyrotomy—needle No No No Yes
14 Airway/Ventilation/Oxygenation Cricothyrotomy—open/surgical No No No Yes
15 Airway/Ventilation/Oxygenation Cricothyrotomy—overwire (Seldinger) technique No No No Yes
16 Airway/Ventilation/Oxygenation End tidal CO2 monitoring/
capnography
No No Yes Yes
17 Airway/Ventilation/Oxygenation Esophageal obturator airway (EOA)/esophageal gastric tube airway (EGTA) No No No No
18 Airway/Ventilation/Oxygenation Extubation—removal of ETT No No No Yes
19 Airway/Ventilation/Oxygenation Gastric decompressions—
Orogastric or nasogastric tube insertion
No No No Yes
20 Airway/Ventilation/Oxygenation Gastric decompression by alternative/rescue airway (CombiTubeTM or King LTS-DTM) No No Yes Yes
21 Airway/Ventilation/Oxygenation Head-tilt/chin lift Yes Yes Yes Yes
22 Airway/Ventilation/Oxygenation Inspiratory Impedance Threshold Device (ITD) No No Yes1 Yes
23 Airway/Ventilation/Oxygenation Endotracheal Intubation—by direct laryngoscopy (including video intubation devices), nasotracheal, digital and transillumination/
lighted stylet techniques
No No No Yes
24 Airway/Ventilation/Oxygenation Endotracheal Intubation—paralytic assisted, rapid sequence induction (RSI) No No No No
25 Airway/Ventilation/Oxygenation Ventilation—maintenance of previously initiated neuromuscular blockade No No No No
26 Airway/Ventilation/Oxygenation Endotracheal Intubation—
retrograde technique
No No No No
27 Airway/Ventilation/Oxygenation Jaw thrust and modified jaw thrust (trauma) Yes Yes Yes Yes
28 Airway/Ventilation/Oxygenation Laryngeal mask airway (LMA) No No No No
29 Airway/Ventilation/Oxygenation Mouth-to-mouth, nose, stoma, barrier and pocket mask Yes Yes Yes Yes
30 Airway/Ventilation/Oxygenation Obstruction—direct laryngoscopy (remove with forceps) No No No Yes
31 Airway/Ventilation/Oxygenation Obstruction—manual (abdominal thrusts, finger sweep, chest thrusts) upper airway Yes Yes Yes Yes
32 Airway/Ventilation/Oxygenation Oxygen therapy—blow-by delivery Yes Yes Yes Yes
33 Airway/Ventilation/Oxygenation Oxygen therapy—humidifiers No Yes Yes Yes
34 Airway/Ventilation/Oxygenation Oxygen therapy—nasal cannula Yes Yes Yes Yes
35 Airway/Ventilation/Oxygenation Oxygen therapy—nonrebreather Yes Yes Yes Yes
36 Airway/Ventilation/Oxygenation Oxygen therapy—partial rebreather No Yes Yes Yes
37 Airway/Ventilation/Oxygenation Oxygen therapy—regulators Yes Yes Yes Yes
38 Airway/Ventilation/Oxygenation Oxygen therapy—simple face mask No Yes Yes Yes
39 Airway/Ventilation/Oxygenation Oxygen therapy—Venturi mask No Yes Yes Yes
40 Airway/Ventilation/Oxygenation Peak expiratory flow assessment No No Yes Yes
41 Airway/Ventilation/Oxygenation Suctioning—meconium aspiration No No No Yes
42 Airway/Ventilation/Oxygenation Suctioning—stoma/tracheostomy Yes Yes Yes Yes
43 Airway/Ventilation/Oxygenation Suctioning—tracheobronchial by advanced airway No Yes2 Yes Yes
44 Airway/Ventilation/Oxygenation Suctioning—upper airway (nasal) Yes Yes Yes Yes
45 Airway/Ventilation/Oxygenation Suctioning—upper airway (oral) Yes Yes Yes Yes
46 Airway/Ventilation/Oxygenation Transtracheal jet ventilation No No No Yes
47 Airway/Ventilation/Oxygenation Single mode, volume controlled automated ventilator (without blender) No Yes1 Yes1 Yes1
48 Airway/Ventilation/Oxygenation Ventilators, transport—single or multi-modal, with or without blender, using volume control mode only, on patients >1 year of age with no anticipated need to actively titrate ventilator settings during transport No No No Yes1
49 Airway/Ventilation/Oxygenation Ventilators, transport—
multimodal, on patients requiring pressure control, pressure support or other advanced setting or anticipated need to actively titrate ventilator settings during transport regardless of ventilation mode
No No No No
50 Cardiovascular/Circulation Blood pressure—auscultation Yes Yes Yes Yes
51 Cardiovascular/Circulation Blood pressure—electronic noninvasive Yes Yes Yes Yes
52 Cardiovascular/Circulation Blood pressure—palpation Yes Yes Yes Yes
53 Cardiovascular/Circulation Electrocardiogram (ECG) monitoring—apply electrodes for single leads No Yes2 Yes2 Yes
54 Cardiovascular/Circulation Electrocardiogram (ECG) monitoring—obtain and transmit 12-lead ECG No No Yes Yes
55 Cardiovascular/Circulation Electrocardiogram (ECG) monitoring—12-lead (interpret) No No No Yes
56 Cardiovascular/Circulation Cardiac monitoring—single lead (interpret) No No No Yes
57 Cardiovascular/Circulation Manual chest compressions—adult, child, infant Yes Yes Yes Yes
58 Cardiovascular/Circulation Cardioversion—synchronized No No No Yes
59 Cardiovascular/Circulation Carotid massage (vagal maneuvers) No No No Yes
60 Cardiovascular/Circulation Defibrillation—counter shock—
manual
No No No Yes
61 Cardiovascular/Circulation Transcutaneous cardiac pacing No No No Yes
62 Cardiovascular/Circulation Transvenous or Epicardial pacing, Management of No No No No
63 Cardiovascular/Circulation Defibrillation—automated external defibrillator (AED) Yes Yes Yes Yes
64 Cardiovascular/Circulation Hemodynamic monitoring/assist (Swan Ganz, central venous pressure) No No No No
65 Cardiovascular/Circulation Intra-aortic balloon pump or invasive cardiac assist device monitoring/assist No No No No
66 Cardiovascular/Circulation Mechanical chest compression device use No Yes1 Yes1 Yes1
67 Cardiovascular/Circulation Thrombolytic therapy—initiation No No No No
68 Cardiovascular/Circulation Thrombolytic therapy—monitoring No No No No
69 IV Initiation/Maintenance/Fluids Central venous cannulation/
insertion
No No No No
70 IV Initiation/Maintenance/Fluids Central venous line—access of existing catheters with external ports No No No Yes
71 IV Initiation/Maintenance/Fluids External jugular vein cannulation No No No Yes
72 IV Initiation/Maintenance/Fluids Saline lock insertions as no-flow IV No No Yes Yes
73 IV Initiation/Maintenance/Fluids Intraosseous—needle placement and infusion—tibia, femur and humerus No No Yes3 Yes
74 IV Initiation/Maintenance/Fluids IV insertion, peripheral venous—
initiation (cannulation)
No No Yes Yes
75 IV Initiation/Maintenance/Fluids Sub-cutaneous indwelling catheters—access of existing catheters No No No No
76 IV Initiation/Maintenance/Fluids Venous blood sampling, peripheral—for clinical diagnostic purposes only No No Yes3 Yes
77 IV Initiation/Maintenance/Fluids Venous blood sampling, peripheral—for legal purposes only (Applies to Paramedics only, as defined and permitted by Act 142 of 2016) No No No Yes
78 IV Initiation/Maintenance/Fluids Venous central line (blood sampling)—obtaining No No No No
79 IV Initiation/Maintenance/Fluids Arterial line—capped—transport No Yes Yes Yes
80 IV Initiation/Maintenance/Fluids Arterial line—monitoring/assist No No No No
81 IV Initiation/Maintenance/Fluids Blood/Blood-by-products administration (initiation and continuation) No No No No
82 Lifting and Moving
Patient lifting, moving and transfers Yes Yes Yes Yes
83 Lifting and Moving
Patient restraints on transport devices Yes Yes Yes Yes
84 Medication administration routes Endotracheal (ET) No No No Yes
85 Medication administration routes Inhalation (aerosolized/nebulized) No No Yes Yes
86 Medication administration routes Intramuscular (IM) No No Yes Yes
87 Medication administration routes Intranasal (IN) No No Yes Yes
88 Medication administration routes Intraosseous (IO)—tibia, humerus or femur No No No Yes
89 Medication administration routes Intravenous (IV)—fluid bolus No No Yes Yes
90 Medication administration routes Intravenous (IV)—monitoring or maintaining existing intravenous infusion (crystalloid fluid as published in the EMS medication list in the Pennsylvania Bulletin) during interfacility transport No No Yes Yes
91 Medication administration routes Intravenous (IV) infusion, with added medication, including by intravenous pump No No No Yes
92 Medication administration routes Nasogastric No No No Yes
93 Medication administration routes Enteral feeding devices, Management of No No No No
94 Medication administration routes Oral—glucose and aspirin (other medications addressed elsewhere) No Yes Yes Yes
95 Medication administration routes Rectal No No No Yes
96 Medication administration routes Subcutaneous No No Yes Yes
97 Medication administration routes Sublingual (Note: EMT may only assist patient with his/her prescribed Nitroglycerin (NTG)) No Yes Yes Yes
98 Medication administration routes Topical No No No Yes
99 Medications Auto—injector benzodiazepine for seizure No No No Yes
100 Medications Auto—injector epinephrine (assist patient with his/her prescribed medication) No Yes Yes Yes
101 Medications Auto—injected epinephrine—
primary use—not patient's own prescription
No Yes1 Yes Yes
102 Medications Medications as published in Pennsylvania Bulletin by the Department Yes Yes Yes Yes
103 Medications Immunizations as published in the Pennsylvania Bulletin by the Department No No Yes Yes
104 Medications Over-the-counter (OTC) medications (Note: aspirin and glucose covered elsewhere) No No No No
105 Medications Oxygen Yes1 Yes Yes Yes
106 Medications Auto-injector nerve agent antidote—self or peer rescue Yes Yes Yes Yes
107 Medications Auto-injector nerve agent antidote—patient treatment No Yes3 Yes3 Yes
108 Medications Metered-dose inhaler (MDI) bronchodilator (Note: EMT may only assist patient with his/her own prescribed medication) No Yes Yes Yes
109 Medications Naloxone—Intranasal or auto-injector Yes1,6 Yes1,6 Yes Yes
110 Patient assessment/management Behavioral—Restrain violent patient Yes1 Yes Yes Yes
111 Patient assessment/management Blood glucose assessment No Yes1 Yes Yes
112 Patient assessment/management Portable blood analysis devices, use of (glucometer covered elsewhere) No No No No
113 Patient assessment/management Childbirth—umbilical cord cutting Yes Yes Yes Yes
114 Patient assessment/management Childbirth (abnormal/
complications)
No Yes Yes Yes
115 Patient assessment/management Childbirth (normal)—cephalic delivery Yes Yes Yes Yes
116 Patient assessment/management Carbon Monoxide CO-oximetry monitoring No Yes1 Yes1 Yes1
117 Patient assessment/management Carbon Monoxide monitoring, with environmental surveillance devices Yes Yes Yes Yes
118 Patient assessment/management Hemodynamic monitoring/assist (Swan Ganz, central venous pressure) No No No No
119 Patient assessment/management Dislocation reduction No No No No
120 Patient assessment/management Eye irrigation (Note: irrigation through corneal contact device limited to AEMT and Paramedic) Yes Yes Yes Yes
121 Patient assessment/management Intracranial monitoring/assist No No No No
122 Patient assessment/management Patient management per Statewide EMS Protocols and Department approved protocols Yes Yes Yes Yes
123 Patient assessment/management Pulse oximetry monitoring No Yes Yes Yes
124 Patient assessment/management Splinting, extremity—manual, rigid, soft, vacuum No Yes Yes Yes
125 Patient assessment/management Splinting, femur—traction No Yes Yes Yes
126 Patient assessment/management Urinary catheterization No No No No
127 Patient assessment/management Wound care, dressing, bandaging Yes Yes Yes Yes
128 Patient assessment/management Wound care, removal of Taser probe/barb No No No No
129 Patient assessment/management Wound drainage vacuum devices, monitoring No Yes Yes Yes
130 Patient assessment/management Wound care, hemorrhage control—direct pressure, tourniquet, bandaging, hemostatic agents Yes Yes Yes Yes
131 Patient assessment/management Wound care, irrigation and skin closure with tape or adhesive glue No No No No
132 Spine Care Restrict spinal motion—Cervical collar application No Yes Yes Yes
133 Spine Care Restrict spinal motion—Helmet removal or stabilization No Yes Yes Yes
134 Spine Care Restrict spinal motion—manual cervical spine stabilization Yes Yes Yes Yes
135 Spine Care Restrict spinal motion—rapid extrication with precautions to restrict spinal movement No Yes Yes Yes
136 Spine Care Devices to restrict spinal motion—for example—vacuum mattress, extrication devices, scoop stretcher and spine board) No Yes Yes Yes

 EMR—Emergency Medical Responder; EMT—Emergency Medical Technician; AEMT—Advanced Emergency Medical Technician; P*—Paramedic (*includes—PHRN/PHPE/PHP)

 No—The skill is not in the scope of practice for the level of certification.

 Yes—The skill is in the scope of practice for the level of certification.

 1. Additional training and authorization by EMS agency medical director is required, and this skill may only be used when functioning with a licensed EMS agency that complies with Department requirements for providing this skill.

 2. May assist a P, PHRN, PHPE or PHP with this skill only when in the physical presence of and under the direct supervision of the higher level provider.

 3. May perform this skill only in the physical presence of and under the direct supervision of a P, PHRN, PHPE or PHP.

 4. After July 1, 2015, Statewide ALS Protocol will include any restrictions placed upon the use of this skill.

 5. This skill becomes effective July 1, 2015.

 6. Department-approved Act 139 training required and approval of the EMS medical director, and this skill may only be used when functioning with a licensed EMS agency that complies with Department requirements for providing this skill.

KAREN M. MURPHY, PhD, RN, 
Secretary

[Pa.B. Doc. No. 17-965. Filed for public inspection June 9, 2017, 9:00 a.m.]



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