Opinion No.

The Honorable Don R. House State Representative P.O. Box 505 Walnut Ridge, AR 72476-0505

Dear Representative House:

You have requested my opinion on the following questions:

(1) If paramedics are restricted by law from administering care within the scope of their training in a hospital under the supervision of emergency room physicians, what are those restrictions?

(2) Are paramedics restricted from using their skills in a hospital as a continuation of the initial care given outside the hospital? Can they provide services to patients for whom they did not initiate treatment outside the hospital (i.e., patients who come to the emergency room by private vehicle or other means)?

(3) Can paramedics work within their scope of skills as outlined for emergency services promulgated under the authority of Act 475 of 1975 in an emergency room, under the supervision of a medical doctor as an employee of a hospital?

RESPONSE

Question 1 — If paramedics are restricted by law from administering carewithin the scope of their training in a hospital under the supervision ofemergency room physicians, what are those restrictions?

Paramedics and other emergency medical technicians¹ who are certified by the State Department of Health are governed by the rules and regulations that have been promulgated by the State Board of Health. A.C.A. § 20-13-208.

The Board has promulgated rules and regulations that establish the permissible scope of practice for paramedics (and other emergency medical technicians). The rules and regulations specifically list the procedures that paramedics can perform under the supervision of a physician. Paramedics are restricted to performing those listed procedures under the supervision of a physician. The pertinent provision of the rules and regulations states:

a. Emergency Medical Technician-Paramedic when appropriate, may perform the following skills with Medical Director oversight:

1). Advanced life support (ALS) skills:

a). Administration of approved intravenous fluids

b). Airway maintenance and ventilatory support including endotracheal intubation, nasotracheal intubation, cricothyroidotomy, and needle thoracostomy

c). Administration of approved drugs

d). Electrocardiogram monitoring and interpretation

e). Defibrillation and synchronized cardioversion

f). Oralgastric and nasogastric insertion, lavage and suction

g). Additional procedures and skills as recommended by the Governor's EMS Advisory Council and approved by the Department.

2). Basic Life Support (BLS) skills:

a). Airway maintenance and ventilatory support

b). Obtaining and monitoring vital signs

c). Cardiopulmonary resuscitation (CPR)

d). Defibrillation with an Automated External Defibrillator (AED)

e). Performing scene assessment, patient assessment and triage

f). Bleeding control, wound care, and treatment for shock

g). Fracture immobilization

h). Management of medical, traumatic, and behavioral emergencies

i). Gaining access to patients and extricate for treatment and transport

j). Use of emergency medical services communication equipment

k). Provide verbal patient reports and written run documentation to the care facility as required

l). Additional procedures and skills as recommended by the Governor's EMS Advisory Council and approved by the Department.

Arkansas State Board of Health's Rules and Regulations Pertaining toEmergency Medical Services, § VII.²

The term "Medical Director," as used in the above quoted provision, is defined for purposes of the rules and regulations as follows:

Q. Medical Director: The Arkansas licensed physician, who is either certified in: Advanced Cardiac Life Support, or is Board Certified by the American Board of Emergency Medicine, in a supervisory capacity and registered with the Department as such.

Arkansas State Board of Health's Rules and Regulations Pertaining toEmergency Medical Services, § I (Q) (Definitions).

Paramedics are restricted to performing the above outlined procedures under the supervision of an appropriate physician.

Question 2 — Are paramedics restricted from using their skills in ahospital as a continuation of the initial care given outside thehospital? Can they provide services to patients for whom they did notinitiate treatment outside the hospital (i.e., patients who come to theemergency room by private vehicle or other means)?

The Arkansas State Board of Health's Rules and Regulations Pertaining to Emergency Medical Services include a section that addresses this question. Section VIII of those rules and regulations states in full:

SECTION VIII. HOSPITAL STAFFING

Pursuant to ACT 293 of 1981, if a hospital wishes to permit an Arkansas Certified Emergency Medical Technician to perform specified procedures within the Emergency Department or as a member of an emergency code team functioning elsewhere in the hospital, the following action must be taken:

A. The medical staff must approve the privileges granted to the individual functioning as an EMT with the concurrence of the hospital's governing body. Specific policies governing the supervision and the procedures to be performed by the EMT must be developed by the medical staff and also approved by the hospital's governing body. In no event, however, may an EMT perform a procedure on a patient in a hospital that he or she is not certified to do by the Office of EMS and Trauma Systems, Arkansas Department of Health.

B. Approved EMTs in a hospital setting must function in accordance with physician's orders and under the direct supervision of either the physician or the Registered Nurse responsible for emergency services within a hospital.

C. In addition, with hospital concurrence, students in EMT training programs approved by the Office of Emergency Medical Services and Trauma Systems of the Arkansas Department of Health must be trained by qualified personnel within the hospital under guidelines established by the medical staff and approved by the hospital governing body.

D. A roster with the delineation of privileges will be maintained in the files of the supervisor for the respective department of employment and in the files of the administrator.

Arkansas State Board of Health's Rules and Regulations Pertaining toEmergency Medical Services, § VIII.

The provision quoted above appears to delegate to each hospital's governing body the decision as to whether emergency medical technicians can perform their functions in the hospital. As indicated in Subsection A above, however, an emergency medical technician cannot under any circumstances perform functions that he or she is not certified to perform. If a particular procedure requires supervision by a physician, paramedics must restrict their performance of such procedures to situations in which they will be supervised as required by the Board's rules and regulations.

I am aware that some concern may arise with regard to whether permitting paramedics to perform their functions in hospitals would place nurses in the position of delegating functions in violation of their own governing laws, rules, and regulations. Nurses are subject to numerous restrictions concerning the delegation of nursing tasks. See Rules and Regulations ofthe State Board of Nursing, Chapter 5 (Delegation). However, the chapter governing delegation by nurses contains the following exception:

These sections shall not be construed to apply to:

* * *

3. Acts done by persons licensed by any board or agency of the State of Arkansas if such acts are authorized by such licensing statutes;

Rules and Regulations of the State Board of Nursing, Chapter 5 (Delegation).

It is my opinion that the above quoted provision from the rules and regulations of the State Board of Nursing should alleviate concern about delegation in appropriate circumstances (e.g., circumstances under which the required supervision is provided) to a paramedic of a task that the paramedic is licensed to perform.

Question 3 — Can paramedics work within their scope of skills as outlinedfor emergency services promulgated under the authority of Act 475 of 1975in an emergency room, under the supervision of a medical doctor as anemployee of a hospital?

See response to Questions 1 and 2.

Assistant Attorney General Suzanne Antley prepared the foregoing opinion, which I hereby approve.

Sincerely,

MIKE BEEBE Attorney General

¹ The Board's rules and regulations provide for the following levels of emergency medical certification:

a. Advanced Life Support

1). Emergency Medical Technician-Paramedic

2). Emergency Medical Technician-Intermediate

b. Basic Life Support

Emergency Medical Technician-Ambulance

c. Instructor

1). Emergency Medical Technician-Instructor

2.) Emergency Medical Technician-Instructor Trainer

Arkansas State Board of Health's Rules and Regulations Pertaining toEmergency Medical Services, § VII.

² The functions that can be performed by individuals holding other levels of emergency medical certification are likewise outlined in Section VII of the Board's rules and regulations.