The provision of emergency medical services (EMS) across the country and in Colorado formally began in the 1970s, following the publication of a Congressional study known most commonly as the “EMS White Paper” in 1969. The federal government does not oversee states’ provision of EMS, although the Office of EMS within the National Highway Traffic Safety Administration (NHTSA) offers technical and coordination support to the states.[3] Thus, states implemented the delivery and oversight of EMS according to their individual needs and resources.
Most states have centralized the oversight of all components of the EMS system at the state level, whether within their state health department or similar state agency. (See map of how ground ambulance agency licensing is conducted across the 50 states in Appendix I.) However, Colorado is a diverse, local control state that has centralized some, but not all, components of the healthcare system at the state level (through CDPHE). Like many states, Colorado licenses air ambulance agencies at the state level, but unlike most states, ground ambulance agencies are not licensed by the state. Instead, counties are conferred with the statutory authority to license ground ambulance services.[4] It should be noted that no state law requires that counties actually provide ambulance services.
Additionally, state law does not require that emergency medical services be delivered in a specific manner, and multiple types of EMS systems exist in Colorado. Some jurisdictions provide ambulance services as a county- or special district-based service. Others contract with private, for-profit ambulance companies to service their areas. Many urban areas use a dual response system where a fire department with firefighting personnel, certified or licensed as EMS providers, respond to a scene along with a private ambulance service. In this type of system, although the EMS providers from both agencies provide care, only the private ambulance service transports the patient to a hospital. Colorado state law does require, however, that any person providing direct emergency medical care and treatment to patients transported in an ambulance must, at minimum, possess an EMS provider certificate or license issued by CDPHE.[5]
Until recently, state law provided only a certification pathway for EMS providers to practice in Colorado. The law was modified to allow EMS providers the option to pursue a licensure pathway by providing proof of completing a four-year bachelor’s degree from an accredited college or university in specified fields.[6] However, the licensure pathway does not change the scope of practice; EMS providers perform the same work related functions/duties whether they are certified or licensed.
Applicants for EMS provider certification or licensure are required to complete a CDPHE-approved education program, pass a national exam, and satisfy CDPHE’s application requirements. State certification or licensure allows EMS providers to practice, but only if they are practicing under the direction of a licensed physician medical director. The acts and medications that an EMS provider is authorized to perform and administer are based upon the EMS provider’s education and training, as well as their medical director’s approval, and are known as the EMS provider’s “scope of practice.” EMS providers are trained to create accurate field impressions and assess the possible causes of a patient’s presentation to focus treatment efforts, prioritize interventions, and determine hospital disposition.
Scopes of practices are set individually by states; the federal government does not regulate EMS providers’ certification/licensure or their scopes of practice. In Colorado, EMS providers’ scopes of practice are set forth in Chapter 2 of the rules promulgated by CDPHE’s executive director if that role is filled by a physician, or by the chief medical officer if the executive director is not a physician.[7] The rules set forth the acts and medications for each level of provider in a table format that contains a Y (yes) or N (no), indicating whether that level of provider is authorized to perform/administer each specific act or medication.[8]
Colorado bases its scopes of practice on those developed through NHTSA’s Office of EMS, including the National EMS Scope of Practice Model and the National EMS Education Standards. Colorado may modify the national scope of practice to match the particular needs of the state by gathering the expertise of Colorado’s emergency medical and trauma system stakeholders and deliberating in public meetings of the EMPAC. Once consensus is reached, the acts and skills are recommended for approval by the EMPAC to CDPHE and eventually adopted in a rule-making hearing by CDPHE’s chief medical officer, pursuant to the state Administrative Procedure Act.
Colorado has four certification/licensure levels of EMS providers, listed in the table below in ascending order based on the level of services that they provide, along with the current numbers of each level of certified/licensed providers in the state. A column with the approximate hours of initial education required has been provided for context. Note that education is now competency-based instead of based on coursework hours, but this information gives some sense of the differentiation between EMS provider levels. See Table 1.
| Type | Level of Service | Education (approximates) | # of Providers (as of 2021 Q1) |
| Emergency Medical Technician (EMT) | Provides basic emergency medical care; examples include splinting, oxygen administration | 160-200 hrs or 1 semester |
13,663 |
| Advanced Emergency Medical Technician (AEMT) | Provides limited acts of advanced emergency medical care; examples include all EMT skills plus IV administration, limited invasive procedures, medication administration | 250 hours or 1 semester | 381 |
| Emergency Medical Technician - Intermediate (EMT-I) | Provides limited acts of advanced emergency medical care; examples include all EMT and AEMT skills plus advanced airway/ endotracheal tube insertion, chemical restraints |
400 hours or 2 semesters | 384* |
| Paramedic | Provides acts of advanced emergency medical care; examples include all EMT, AEMT, EMT-I skills plus cricothyroidotomy, chemical restraints |
1,500-2,000 hours or 4-6 semesters | 5,015 |
*The EMT-I level was sunsetted as part of a national standardization effort. A few EMT-Is still remain in practice, but once they retire this level will no longer exist.
Another important component of the EMS system is EMS medical direction. All ambulance agencies, as well as non-transport agencies that utilize EMS providers, must have a physician medical director because in Colorado, EMS providers are not licensed independent practitioners, like doctors and nurses. Instead, state law requires that they practice under the medical direction of a licensed physician.[9] Consequently, all EMS agencies have a physician EMS medical director who oversees the medical care provided by the agency and its personnel.
The primary responsibilities of EMS medical directors are to establish protocols and training for their providers and to perform quality improvement and quality assurance for their providers and agencies. CDPHE has some oversight of EMS medical directors, including setting minimum standards for physicians to be EMS medical directors and defining the physician medical direction required for appropriate oversight of an EMS provider.[10] However, the definitive authority over medical directors is the Colorado Medical Board, the entity that regulates the practice of medicine and oversees physician licenses.
CDPHE’s role in the state’s EMS system is not just a regulatory one. CDPHE works closely with its regulated community and other interested stakeholders to provide resources and technical assistance to ensure not only the public’s health, safety and welfare, but access to care, as well. In so doing, it relies on two advisory councils: 1) the State Emergency Medical and Trauma Services Advisory Council (SEMTAC), a 32-member type 2 board[11] that advises CDPHE on all matters related to emergency medical and trauma services, and 2) the EMPAC, another type 2 board that is smaller than SEMTAC and whose role is to provide general technical expertise on matters specifically related to the provision of care by EMS providers. These two boards are advisory to CDPHE, meaning they review and make recommendations but do not have authority to act on behalf of CDPHE.
Until the 2021 legislative session, the EMPAC consisted of 11 members, eight of whom were appointed by the Governor. Of the appointed members, five are EMS medical directors and three are various levels of EMS providers. House Bill 21-1251 modified EMPAC’s membership to 13 to include two additional appointed members: a clinical psychiatrist and an anesthesiologist. The EMPAC is discussed throughout this report due to the council’s specific responsibility of making recommendations to CDPHE on EMS scope of practice and on waivers to scope of practice.