Education, the Registry, quality improvement and medical direction

1. You findYou have passed your course and want national certification.You doThe NREMT sets and maintains national standards and registers EMRs, EMTs, AEMTs and paramedics. For an EMT, that means passing the NREMT computer-based knowledge (cognitive) exam and showing skills competence in a practical exam, which today is approved or verified by your state or your program.
2. You findTime passes, and EMS knowledge and procedures keep changing.You doCertification is not permanent. Complete refresher training to recertify (NREMT certification renews every 2 years; state periods vary, roughly 2 to 4 years), and add continuing education such as conferences, classes and videos.
3. You findA patient's condition is covered by your protocols and standing orders.You doAct without contacting a physician. This is off-line medical direction. Giving naloxone for an opioid overdose is an example where standing orders allow it.
4. You findYou want to give a medication or treatment that your standing orders do not cover.You doContact an on-duty physician by phone or radio and get a real-time order first. This is on-line medical direction.
5. You findThe call is over.You doSupport quality improvement: write an accurate and complete report, critique your own performance, gather feedback, maintain your equipment and keep learning.

• Refresher training is required periodically to recertify. Continuing education supplements your original training; it does not replace it.
• The NREMT sets and maintains national standards and registers all four levels. National registration helps with reciprocity, the transfer of certification from one state to another, and employers look on it favorably. Most states use the NREMT exam as their own certification exam.
• Quality improvement (QI) is the continuous self-review of an EMS system to find and fix problems, so that prehospital care is of the highest quality.
• EMTs support QI by writing accurate, complete reports, serving on QI committees, critiquing their own performance after each call, gathering feedback from patients and hospitals, maintaining equipment and continuing their education.
• The Medical Director is the physician with ultimate responsibility for the patient-care side of the system: the protocols, oversight of training and a central role in QI.
• Off-line medical direction is standing orders: you act without contacting a physician. On-line medical direction is a real-time order from an on-duty physician by phone or radio.

The wrong idea: Quality improvement is how the service finds out who made a mistake and punishes them.

What is actually true: QI is continuous self-review of the whole system to find and fix problems. EMTs are part of it, not targets of it: your accurate reports, honest self-critique after calls and equipment checks are what make it work.

Certification has to be kept up: refresher training is required to recertify, and continuing education supplements the original course because EMS practice keeps changing. The NREMT sets national standards and registers EMRs, EMTs, AEMTs and paramedics; registration helps with reciprocity between states. Quality improvement is the continuous self-review of the system, and EMTs support it with accurate reports, self-critique, feedback, equipment maintenance and continued learning. Every system works under a physician Medical Director. Off-line medical direction is standing orders you follow without a call; on-line medical direction is a real-time order from an on-duty physician by phone or radio.

EMS in public health and evidence-based practice →