DEPARTMENT OF HEALTH
Scope of Practice for Critical Care Transport Emergency Medical Service Providers
[50 Pa.B. 413]
[Saturday, January 18, 2020]
Under 28 Pa. Code § 1027.39(d) (relating to critical care transport ambulance service), the Department of Health (Department) is publishing the expanded scope of practice for authorized paramedics (P), prehospital registered nurses (PHRN), prehospital physician extenders (PHPE) and prehospital emergency medical services physicians (PHP) when functioning for an emergency medical service (EMS) agency that has been licensed as a critical care transport (CCT) ambulance service under 35 Pa.C.S. § 8129 (relating to emergency medical services agencies).
Under § 1027.39(d), expansion of the applicable EMS providers' scopes of practice include EMS skills in addition to those skills included in these EMS providers' general scopes of practice that were published at 50 Pa.B. 415 (January 18, 2020). To perform these expanded skills, EMS providers must receive education to perform these skills by having successfully completed a CCT educational program approved by the Department. Minimum requirements to become an approved CCT educational program, and a list of approved CCT educational programs, will be continuously updated on the Bureau of Emergency Medical Services' web site.
Skills identified may be performed by these EMS providers only if the provider has successfully completed training (cognitive, affective and psychomotor) on the specified skill, which includes training to perform the skill on adults, children and infants, as appropriate. These providers may only perform skills that are indicated through either Statewide or other Department-approved protocols or that are ordered online by a medical command physician.
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—422.53) or the Osteopathic Medical Practice Act (63 P.S. §§ 271.1—271.18), whichever applies to the physician assistant, when authorized by a medical command physician through either online medical command or through the applicable Statewide or Department-approved EMS protocols. When a PHPE functions in this capacity, the physician supervision requirements applicable to a physician assistant under the Medical Practice Act of 1985 or 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, whichever applies to the physician. A PHP may not perform a skill that the PHP has not been educated and trained to perform.
To administer medications in addition to those permitted by applicable medical treatment protocols, PHRNs, PHPEs and PHPs must also receive approval to do so by the EMS agency medical director of the advanced life support ambulance service under which they are functioning.
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 advanced emergency medical technician (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.
Category Skill Critical Care Transport Provider (P, PHRN, PHPE or PHP) 1 Airway/ventilation/oxygenation Chest tube thoracostomy, monitoring of existing tube in a closed system (for example water seal or suction) Yes1 2 Airway/ventilation/oxygenation Chest tube thoracostomy, acute insertion Yes2 3 Airway/ventilation/oxygenation Biphasic positive airway pressure (BiPAP) for patients acutely on BiPAP for <48 hours Yes1 4 Airway/ventilation/oxygenation Endotracheal Intubation—paralytic assisted, rapid sequence induction (RSI) Yes2 5 Airway/ventilation/oxygenation Escharotomy Yes2 6 Airway/ventilation/oxygenation Ventilation—Maintenance of previously initiated neuromuscular blockade Yes1 7 Airway/ventilation/oxygenation Laryngeal mask airway (LMA) Yes1 8 Airway/ventilation/oxygenation Ventilators that are portable and capable of being transported with a patient and are multi-modal, with a blender, that are used on patients requiring pressure control, pressure support or other advanced setting, or when there is an anticipated need by a healthcare provider involved with the care of the patient to actively titrate ventilator settings during transport, regardless of ventilation mode Yes1 9 Airway/ventilation/oxygenation Ventilators, transport—used in multi-modal settings, blended gas transport ventilator on patients ventilated <48 hours or anticipated need to actively titrate ventilator settings Yes2 10 Cardiovascular/circulation Transvenous or Epicardial pacing, Management of Yes2 11 Cardiovascular/circulation Hemodynamic monitoring/assist (pulmonary artery catheter, central venous pressure) Yes2 12 Cardiovascular/circulation Intra-aortic balloon pump or invasive cardiac assist device or extracorporeal membrane oxygenation—monitoring/assist Yes2 13 Cardiovascular/circulation Thrombolytic therapy—initiation Yes2 14 Cardiovascular/circulation Thrombolytic therapy—monitoring Yes2 15 IV Initiation/maintenance/fluids Sub-cutaneous indwelling catheters—access of existing catheters Yes1 16 IV Initiation/maintenance/fluids Venous central line (blood sampling)—obtaining Yes1 17 IV Initiation/maintenance/fluids Arterial line—monitoring Yes1 18 IV Initiation/maintenance/fluids Blood products—continued administration of blood products initiated at sending facility Yes1 19 IV Initiation/maintenance/fluids Blood products—initiation of infusion Yes2 20 Medication administration routes Enteral Feeding Devices, Management of Yes1 21 Medications Medications for Critical Care Transport Providers as published in Pennsylvania Bulletin by the Department Yes1 22 Medications Over-the-counter (OTC) medications (Note: aspirin and glucose covered elsewhere) Yes1 23 Patient Assessment/management Portable blood analysis devices, use of (glucometer covered elsewhere) Yes1 24 Patient Assessment/management Intracranial pressure monitoring/assist Yes2 25 Patient Assessment/management Urinary catheterization Yes1
Yes—The skill is in the scope of practice for Ps, PHRNs, PHPEs and PHPs who are authorized to function for an EMS agency that has been licensed as a CCT ambulance service.
1. Ps, PHRNs, PHPEs and PHPs who are authorized to function for an EMS agency that has been licensed as a CCT ambulance service may only perform or assist with these skills during interfacility transport with a CCT ambulance.
2. Ps who are authorized to function for an EMS agency that has been licensed as a CCT ambulance service may assist a PHRN, PHPE or PHP with this skill only during interfacility transport with a CCT ambulance and when in the direct physical presence of, and supervised by, the higher level provider.
Persons with a disability who require an alternate format of this notice (for example, large print, audiotape, Braille) should contact Aaron M. Rhone, EMS Program Manager, Department of Health, Bureau of Emergency Medical Services, 1310 Elmerton Avenue, Harrisburg, PA 17110, (717) 787-8740. Speech or hearing-impaired persons may call the Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
RACHEL L. LEVINE, MD,
[Pa.B. Doc. No. 20-79. Filed for public inspection January 17, 2020, 9:00 a.m.]
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