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SCOPE OF PRACTICE December 2020

About Practice Directions The College of Paramedics of Manitoba (CPMB) has the legislated authority through the Regulated Health Professions Act (RHPA) to establish Council-approved practice directions. Practice directions set out requirements related to specific aspects of the RHPA, regulations and paramedic practice. Practice Directions also explain, add, or guide paramedics with respect to the subject matter described in the regulation or any other matter relevant to the practice of paramedicine. Compliance with approved practice directions is required as described under section 86 of the RHPA. Questions related to the information in the College practice directions or the application of the information can be directed in [email protected]. This Practice Direction was approved by the Transitional Council of the College of Paramedics of Manitoba on November 27, 2020.

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Table of Contents Page Paramedic Scope of Practice ........................................................................ 4

Appendix A – Delegation Flow Chart ......................................................... 11

Appendix B – EMR .................................................................................... 14

Appendix C – PCP ...................................................................................... 22

Appendix D – ICP ...................................................................................... 44

Appendix E – ACP ...................................................................................... 65

Appendix F – CCP ..................................................................................... 101

Paramedic Scope of Practice Purpose

The purpose of this document is to provide information about the scope of practice for paramedics in Manitoba under The Regulated Health Professions Act (RHPA). Where necessary, additional scope of practice information will be included in the College’s practice directions. Scope of Practice of the Paramedic Profession in Manitoba

Scope of practice refers to the application of paramedic knowledge, skills, and judgement to the actual practice of paramedicine. The legal authority for Manitoba’s paramedic scope of practice is found in the Practice of Paramedicine Regulation. (Links to all relevant legislation can be found at the end of this document.) The scope of practice outlines the boundaries of practice for the paramedic profession. These boundaries are broad because the paramedic profession encompasses 4 different levels of paramedic education, training, and practice level. The Practice of Paramedicine Regulation defines the paramedic scope of practice as: The application of knowledge, skill, and judgment for:

(a) The assessment, management, and treatment of: i. an individual’s injury or illness that arises from a health emergency; or

ii. an individual for the purpose of providing health care to that individual, which may include making referrals to other health or social programs or services; and

(b) The provision of health education and health promotion programs to an individual.

The application of that knowledge, skill and judgment takes place in a variety of practice settings, such as in an individual’s residence, in the community, in a vehicle while transporting an individual, or in a health care facility, such as a hospital or other clinical practice setting. The RHPA sets out the conditions for each profession to determine the reserved acts that align with the education, knowledge, and service provided by that profession. The reserved acts are clinical activities done in the course of providing health care that can present a risk of harm to the public when performed incompetently. Reserved acts are to be limited to certain regulated health professions, and registrants of those professions, who are qualified and competent to perform them.

The College of Paramedics of Manitoba General Regulation further outlines paramedic scope of practice under the RHPA’s reserved act model. A paramedic may perform a reserved act only if:

• The reserved act is listed in the College of Paramedics of Manitoba General Regulation. • The paramedic meets the criteria for the reserved act. • The reserved act is within the individual paramedic’s scope of practice; and • The paramedic works within the practice settings outlined in the Practice of

Paramedicine Regulation definition of scope of practice and within RHPA, College regulations, bylaws, practice directions and Code of Ethics.

• Employer’s policies are consistent with the RHPA, College regulations, bylaws, practice directions and Code of Ethics.

Even though much of the discussion in the remainder of this document describes the reserved acts that are within the paramedic scope of practice, it is important to know that the paramedic scope of practice is not solely encompassed in these reserved acts. The breadth and varying depths of the paramedic scope of practice cannot be described by reserved acts alone.

Some Examples of Paramedic Practice that are not Reserved Acts under the RHPA:

• Maintaining professionalism, participating in quality assurance and enhancement programs, • Assessing the health status of clients • Planning the paramedic’s treatment of the client • Ongoing evaluations of treatment while in the care of paramedics • Educating, informing, and advising clients who refuse paramedic care • Applying critical thinking • Analyzing data obtained by client assessment, condition of scene, and bystander reports • EKG, Pulse Oximetry, Glucometry, Vital Signs assessment, and other diagnostic tools • Maintaining patient dignity and comfort • Safe transfer of clients from wherever they are encountered to the ambulance stretcher, the

ambulance, or place of safety • Transport of client(s) to appropriate facilities • Discussion, collaboration, and interaction with other health professions • Collaboration with other Emergency Response agencies where required • Developing professional and therapeutic relationships • Documenting timely, accurate Patient Care Reports and other reports • Maintaining safety of self, client, and bystanders in the practice setting • Teaching, mentoring, precepting, and evaluating paramedic students or other health

professional students • Determination of death • Maintaining and ensuring ambulances and equipment are in good working order • Ensuring the ambulance is appropriately stocked with unexpired medications and supplies • Following Infection Prevention and Control policies and procedures and maintaining a clean

ambulance and working environment • Adhering to other applicable Manitoba Acts, such as the Highway Traffic Act and Public Health

Act • Driving in a safe manner, either emergent or non-emergent, while considering safety and

comfort of the client, attending paramedic, and other persons in the ambulance and on the roadways

• Following policies and procedures, protocols, care maps and guidelines provided by employers

Practice Expectations

Practice expectations for paramedics regulate the quality of paramedic practice. A practice expectation is the minimum expectation of performance against which actual performance is compared. It defines reasonable and prudent expectations of all paramedics. In all practice areas, paramedics are expected to:

• Meet any applicable practice directions. • Apply the requisite knowledge, skill, and judgment to competently perform any service

as part of practice. • Function within practice limitations; and • Only perform a reserved act if it is both safe and appropriate for the reserved act to be

provided.

Paramedic Scope of Practice

There are 4 distinct levels of practice spanning 4 sub-register levels for paramedics. These are: • Emergency Medical Responder (EMR) • Primary Care Paramedic (PCP)

o Primary Care Paramedic – Intermediate Care (as a notation on the Certificate of Practice)

• Advanced Care Paramedic (ACP) • Critical Care Paramedic (CCP)

There are specific education, training, and entry to practice requirements for each level of practice. Included in each level of practice is a number of reserved acts that require additional training, provided by the employer, in order for the paramedic to perform those acts. A paramedic’s scope of work may vary from their scope of practice based on their employer’s policies, directions, and additional training, as illustrated in the diagram below

As part of a health care system and team, a paramedic’s training and expertise lie in pre-hospital and out-of-hospital settings and includes non-emergent and emergent responses. The primary purpose of the paramedic is to perform timely interventions while transporting the client to definitive care. Legislation provides authority for the paramedic scope of practice. Limits to scope of practice are defined in regulation. Legislation also sets out the standards of practice which all paramedics must meet in all areas of practice. Employer policies provide further direction on the paramedic practice. An employer may place limits on the practice of paramedics in their employ. An employer’s policies must be consistent with the RHPA, regulations, by-laws, standards of practice, code of ethics and practice directions. An individual paramedic’s scope of practice cannot progress beyond the paramedic’s legislated scope of practice and each individual paramedic must be qualified and competent in their own scope of practice. Authorization Mechanisms

Authorizing mechanisms are a way which paramedics obtain the authority to perform reserved acts. The following authorizing mechanisms are applied to some reserved acts. Standing Orders The definition of a “Standing Order” according to The College of Paramedics of Manitoba General Regulation is: “an instruction or authorization, including one in the form of a protocol, that is given to a member to perform a reserved act by a regulated health professional who is legally permitted and competent to give the order.” Reserved Act 9 states that a standing order is required for medication administration. The Medical Director of the employing organization must issue the standing order, and paramedics must adhere to the contents of that standing order.

Scopeof

Work

Individual Paramedic Register Certificate of

Practice

Legislated Scope of Paramedic Practice

Specific Health Care Needs Requiring Paramedic Response/Transport

Population’s Health Care Needs

Reserved Acts that Cannot be Performed by Paramedics

Reserved Act 1: Making a diagnosis and communicating it to an individual or his or her personal representative in circumstances in which it is reasonably foreseeable that the individual or representative will rely on the diagnosis to make a decision about the individual’s health care.

Reserved Act 3: Performing a procedure on tissue on or below the surface of the cornea Reserved Act 5: Administering a substance using a hyperbaric chamber Reserved Act 6: Prescribing a drug or vaccine Reserved Act 7: Compounding a drug or vaccine Reserved Act 8: Dispensing or selling a drug or vaccine Reserved Act 10: Applying or ordering the application of

(B) electricity for: (i) aversive conditioning (v) Electrocoagulation (vi) Electroconvulsive shock therapy (vii) Electromyography (ix) Nerve conduction studies

(C) Electromagnetism for magnetic resonance imaging (D) other non-ionizing radiation for the purpose of cutting or destroying

tissue or medical imagery (E) X-rays or other ionizing radiation for diagnostic, imaging or therapeutic

purposes, including computerized axial tomography, positron emission tomography and radiation therapy

(F) any other use of a form of energy listed in clauses (a) to , if the use is specified by regulation

Reserved Act 11: In relation to a therapeutic diet that is administered by enteral instillation or parenteral instillation,

(a) selecting ingredients for the diet; or (b) compounding or administering the diet

Reserved Act 12: Casting a fracture of a bone Reserved Act 13: Putting into the external ear canal, up to the eardrum, a substance that

(a) is under pressure; or (b) subsequently solidifies

Reserved Act 15: Administering a high velocity, low amplitude thrust to move a joint of the spine within its anatomical range of motion

Reserved Act 16: Prescribing, dispensing or fitting a wearable hearing instrument Reserved Act 17: Prescribing, dispensing or verifying a vision appliance. Reserved Act 18: Fitting a contact lens Reserved Act 19: Prescribing, dispensing or fitting a dental appliance

Reserved Act 20: Performing a psycho-social intervention with an expectation of modifying a

substantial disorder of thought, mood, perception, orientation or memory that grossly impairs judgement, behavior, the capacity to recognize reality, or the ability to meet the ordinary demands of life.

Reserved Act 21: In relation to allergies: (a) performing challenge testing by any method; or (b) performing desensitizing treatment by any method.

Delegation of Reserved Acts (please refer to the process flow chart in Appendix A) A registrant may delegate the performance of a reserved act to another registrant as provided in clause 6(1)(a) of the Regulated Health Professions Act and 4.8 of the College of Paramedics of Manitoba General Regulation. For paramedics, a “delegation” can occur in two different ways:

• From another regulated health care professional to a paramedic • From one registrant to another (Please note: a reserved act cannot be delegated to an

EMR)

A registrant may delegate the performance of a reserved act to another registrant as provided in the RHPA only if the registrant:

a) Is legally permitted and competent to perform the reserved act being delegated. b) Is satisfied on reasonable grounds that the registrant accepting the delegation is

competent to perform the reserved act. c) Is satisfied on reasonable grounds that it is safe and appropriate for the registrant

accepting the delegation to perform the reserved act; and d) Is readily available for consultation while the registrant accepting the delegation

performs the reserved act.

A registrant is considered competent to perform a reserved act if s/he has the requisite knowledge, skill, and judgment to perform the act. A registrant may accept a delegation of the performance of the reserved act only if:

a) The person who makes the delegation is: i. A registrant of the paramedic profession or another regulated health profession,

ii. Legally permitted and competent to perform the reserved act being delegated, and

iii. Available for consultation during the performance of the reserved act by the regulated registrant under the delegation; and

b) The registrant who accepts the delegation i. Holds a valid certificate of practice

ii. Is competent to perform the reserved act, and iii. Is satisfied on reasonable grounds that it is safe and appropriate to perform the

reserved act

A registrant may perform a reserved act only if: (a) The registrant is legally permitted and competent to perform it and it is safe and

appropriate for the procedure being performed, and (b) It is appropriate to the registrant’s practice setting.

Additional Training

Some reserved acts require the paramedic to successfully complete additional training prior to being permitted to perform the reserved act. Please refer to the College of Paramedics of Manitoba Practice Direction on Additional Training. If the reserved act is appropriate to the licensure level of the paramedic, the paramedic may participate in additional training provided by the employer and approved by the College to ensure that they are competent to perform the act. All training records should be retained by the employer for audit purposes. The College also recommends that each registrant retain his or her own training records. Reserved Acts

This section describes each of the reserved acts and gives illustrative examples at each registrant level. It should be noted that a skill at the EMR level is included in the PCP level, and this continues as the practice levels advance.

It is important for paramedics and employers to understand that College staff is available for consultation regarding any question they may have related to the Reserved Acts, Practice -Directions, or any other directive issued by the College. Please direct inquiries to [email protected] or call 204-793-3592. Appendices A) Practice Direction EMR B) Practice Direction PCP C) Practice Direction ICP D) Practice Direction ACP E) Practice Direction CCP Links to Important Documents:

Practice of Paramedicine Regulation

College of Paramedics General Regulation

Regulated Health Professions Act

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https://collegeparamb.ca/wp-content/uploads/2020/11/Practice-of-Paramedicine-Reg.pdf

https://collegeparamb.ca/wp-content/uploads/2020/11/General-Regulation.pdf

https://web2.gov.mb.ca/laws/statutes/2009/c01509e.php

11 Appendix A – Delegation of Reserved Acts College of Paramedics of Manitoba

APPENDIX A DELEGATION OF RESERVED ACTS

Who can Delegate Reserved Acts?

Regulated

Health Professional

CCP ACP

PCP-IC PCP

CCP ACP PCP-IC

ACP PCP-IC

PCP

PCP-IC PCP

PCP

Delegations cannot be made to EMRs. LIMITATIONS One-time basis specific to client situation and condition. PREFERENCES Delegation to be made in writing (verbal delegation permitted in exigent circumstances).

12 Appendix A – Delegation of Reserved Acts College of Paramedics of Manitoba

Hold a valid Certificate of Practice

Person making the delegation of a Reserved Act.

Are they legally permitted and competent to perform the Reserved Act

being delegated?

Readily available for consultation while the person

performs the Reserved Act.

Satisfied it is safe and appropriate for

the person accepting the delegation to perform the

Reserved Act.

Satisfied the person accepting the delegation is legally permitted and competent to

perform the Reserved Act.

Must be a registrant of the

CPMB or of another regulated health profession.

Person accepting the delegation of a Reserved

Act Be satisfied it is safe and

appropriate to perform the

Reserved Act.

Be competent to perform the Reserved Act.

DOCUMENTATION of the DELEGATION

Client conditions the person making the

delegation considered appropriate

Name or person receiving the delegation

Name of client delegation relates to

Duration of delegation

Signature/title of person making delegation

Reason for delegation

14 Appendix B – EMR Scope of Practice College of Paramedics of Manitoba

Appendix B - Emergency Medical Responder Scope of Practice

Reserved Act Additional

training Required?

Procedure Example Additional Procedural Information

3(a): Performing a procedure on tissue below the dermis

NO

Wound management - irrigating/packing/suturing/other wound closure Management of an impaled object – leaving in situ; removing for specific reasons

To competently and safely perform a procedure on tissue below the dermis the EMR must:

• complete additional training for those purposes that require additional training,

• meet all other practice expectations and applicable practice directions.

• not suture below the fascia.

• not perform procedure on tissue on or below the surface of a tooth or dental implant; and

not perform surgery.

3(b): Performing a procedure on tissue below the surface of the mucous membrane

NO

Wound management Management of an Impaled Object

To competently and safely perform a procedure on tissue below the surface of a mucous membrane the EMR must:



• not suture below the fascia.



Reserved Act Additional training Required?


• not perform surgery.

4(a): Inserting or removing an instrument or device into the external ear canal

NO

Temperature monitoring via tympanic thermometer

To competently and safely perform a procedure of inserting or removing an instrument or device, the EMR must:


• meet all other practice expectations and applicable practice directions

4(b): Inserting or removing an instrument or device beyond the point in the nasal passages where they normally narrow

NO

Basic Airway Management (NPA)




4(c): removing a device beyond the pharynx

YES

Orogastric tube (gravity drain) maintenance, Nasogastric tube maintenance (gravity drain)

To competently and safely perform a procedure of removing a device, the EMR must:


• meet all other practice expectations and




applicable practice directions

4(d): Removing a device from beyond the opening of the urethra

YES

Urinary Catheter Maintenance

To competently and safely perform a procedure of removing a device, the EMR must:



4(e): Inserting or removing a hand or finger beyond the labia majora for obstetrical emergencies

NO

Prolapsed Umbilical Cord Airway Management of the Fetus During Breech Birth

To competently and safely perform a procedure of inserting or removing a hand or finger, the EMR must:



4(e): Inserting or removing a hand or finger beyond the labia majora

YES

Obstetrical Emergencies Related to Limb Presentation

To competently and safely perform a procedure of inserting or removing a hand or finger, the EMR must:






applicable practice directions

4(g): Inserting or removing an instrument or device into an artificial opening in the body

YES

Positive Pressure Ventilation with a Tracheostomy, Suctioning a Tracheostomy




4(g): Inserting or removing an instrument or device into an artificial opening into the body

YES

Managing Obstructed Tracheostomy




5(a): Administering a substance by injection

YES

IV Maintenance

To competently and safely administer a substance according to this reserved act, the EMR must:

• complete additional training for those purposes that require additional training





applicable practice directions.

5(c): Administering a substance by mechanical ventilation

NO

Bag Valve Mask




5(d): Administering a substance

NO

Eye Irrigation





NO

Wound Irrigation







5(e): Administering a substance by enteral instillation or parenteral instillation

YES

Tube Maintenance of an NG tube Tube Maintenance of a PEG tube




9: Administering oxygen

NO

Medication Administration

To competently and safely administer oxygen according to this reserved act, the EMR must:


• receive a standing order where required


9: If there is a standing order, and with additional training, administering a drug, except vaccines, by - auto-injector,

YES


To competently and safely administer a drug according to this reserved act, the EMR must:

• assist the client to self-administer medications except where standing orders/protocols allow administration




- inhalation, metered dose inhaler or nebulizer, - buccal, oral or sublingual routes, - intranasal route




10(b) Applying electricity

NO

AED Without Rhythm Interpretation SAED Without Rhythm Interpretation

To competently and safely apply electricity according to this reserved act, the EMR must:



12: Setting a fracture of a bone for the purpose of

• restoring perfusion, • extrication • immobilization

NO

Fracture Management To competently and safely manage a fracture with a complication, the EMR must:



14: Managing the delivery of a baby only where delivery is imminent while the patient is in the care of a paramedic

NO

Prehospital Delivery To competently and safely manage the labor and delivery of a baby, the EMR must:

• complete additional education for those purposes indicated




above that require additional education

• collaborate with other health-care providers as necessary


Appendix C – PCP Scope of Practice College of Paramedics of Manitoba

22

Appendix C – Primary Care Paramedic Scope of Practice



1: Making a diagnosis that is appropriate to the member's practice of paramedicine and communicating it to an individual or their personal representative in circumstances in which it is reasonably foreseeable that the individual or representative will rely on the diagnosis to make a decision about the individual's health care

NO

Patient Assessment Implementation of specific care map or protocol based on patient assessment Determination of Obvious Death Discontinue (unsuccessful) Basic/Advanced Resuscitation

Diagnoses that are appropriate to the member’s practice of paramedicine should be considered “provisional” and not definitive.

To make a “provisional” diagnosis competently and safely according to this reserved act, the paramedic must apply skills to:

• assess, discern, plan, implement, and evaluate with the goal of improving client outcomes.

• use critical thinking and reasoning skills; and

• explain the provisional diagnosis to the individual and support system


2: With additional training, receiving reports of screening or diagnostic tests for the purpose of assessing, diagnosing or resolving a health condition that is appropriate to the

YES

Tests include: Visualization, Auscultation, Palpation, Thorough history, Pulse, Respirations, Blood Pressure,

Appropriate and thorough use of assessment skills allows for

• confirmation of a diagnosis

• assessment/monitoring of ongoing conditions of


23



paramedic's practice and in accordance with the National Occupational Competency Profile for Paramedics

Temperature, SPO2/ECO2, Blood Glucose, Cardiac monitoring, 12/15 lead acquisition, POCUS, Pulmonary Artery Catheter

clients with chronic illnesses, or

carrying out screening activities


NO

Wound management - irrigating/packing Management of an impaled object – leaving in situ; removing for specific reasons

To competently and safely perform a procedure on tissue below the dermis the Paramedic must:


• meet all other practice expectations and applicable practice directions;

• not suture below the fascia;




YES

Removal of Foreign Body Wound Repair suturing/other wound closure Peripheral IV Cannulation Venous Blood Sample Acquisition





24







NO


To competently and safely perform a procedure on tissue below the surface of a mucous membrane the Paramedic must:






3(d): Performing a procedure on tissue below the surface of a tooth

YES

Emergency Tooth Re-implantation

To competently and safely perform a procedure on tissue below the surface of a tooth, the Paramedic must:



25





NO

Acquisition of Tympanic Temperature

To competently and safely perform a procedure of inserting or removing an instrument or device, the Paramedic must:




NO





4(c): Inserting or removing an instrument or a device beyond the pharynx

YES

Maintenance of established internal esophageal probe Maintenance of established nasogastric


• complete additional training for those


26



tube (non-gravity drain)

purposes that require additional training,



NO


To competently and safely perform a procedure of removing a device, the Paramedic must:



4(c): Inserting a blind insertion airway device beyond the pharynx

NO

BIAD To competently and safely perform a procedure of inserting a device, the Paramedic must:




YES

Removing a Supraglottic Foreign Body




27



purposes that require additional training,



NO





4(d): Removing a urinary catheter

NO

Urinary Catheter Removal





NO

Prolapsed Umbilical Cord Airway Management of the Fetus During Breech Birth

To competently and safely perform a procedure of inserting or removing a hand or finger, the Paramedic must:


28






YES






YES

Obstetrical Emergencies Related to Uterine Inversion




4(f): Inserting or removing an instrument or device beyond the anal verge

Continuous Core Temperature Monitoring

To competently and safely perform a procedure of inserting


29



YES

or removing an instrument or device, the Paramedic must:




NO






YES






30




NO

IV Maintenance

To competently and safely administer a substance according to this reserved act, the Paramedic must:



5(b): Administering a substance by inhalation

Saline administration

NO

Nebulized treatment





NO

Bag Valve Mask





31



applicable practice directions.


YES

Continuous Positive Airway Pressure





NO

Eye Irrigation





NO

Wound Irrigation




32





YES

Bladder Irrigation or Foley catheter irrigation






NO






NO


To competently and safely administer oxygen according to this reserved act, the Paramedic must:


33





9: If there is a standing order, and with additional training, administering a drug, except vaccines, by

• Auto-injector • Inhalation, metered-

dose inhaler or nebulizer

• Buccal, oral or sublingual routes

• Intranasal

NO


To competently and safely administer a drug according to this reserved act, the Paramedic must:


9: If there is a standing order, and with additional training, administering a drug by any method, except vaccines, incidental to the practice of paramedicine ** ** The intention of additional training for this Reserved Act is to ensure pharmacological knowledge rather than knowledge of the route of administration

YES

Medication Administration -Routes of administration include: Subcutaneous (SC); Intramuscular (IM); Intravenous (IV)



• understand indications and contraindications for all medications

• conduct appropriate monitoring after medication administration

• Document all medications given


34




9: Administering a vaccine by any method in accordance with provincial requirements if the vaccine is required as part of a communicable disease response or in a public health emergency

NO

Vaccine Administration



• understand the provincial requirements and protocols


10(b) Applying electricity for automated or semi-automated defibrillation without rhythm interpretation

NO


To competently and safely apply electricity according to this reserved act, the Paramedic must:



10(b) Applying electricity for non-automated defibrillation

YES

Manual Defibrillation




35



purposes that require additional training





NO

Fracture Management

To competently and safely manage a fracture with a complication, the Paramedic must:




NO

Prehospital Delivery To competently and safely manage the labor and delivery of a baby, the Paramedic must:

• complete additional education for those purposes indicated above that require additional education



37 Appendix D – ICP Scope of Practice College of Paramedics of Manitoba

Appendix D – Intermediate Care Paramedic Scope of Practice




NO








2: With additional training, receiving reports of screening or diagnostic tests for the purpose of assessing, diagnosing or resolving a health condition that is appropriate to the

YES

Tests include: Visualization, Auscultation, Palpation, Thorough history, Pulse, Respirations, Blood Pressure, Temperature, SPO2/ECO2, Blood Glucose, Cardiac monitoring, 12/15



• assessment/monitor-ing of ongoing conditions of clients




paramedic's practice and in accordance with the National Occupational Competency Profile for Paramedics

lead acquisition, POCUS, Pulmonary Artery Catheter

• with chronic illnesses, or



NO







not perform surgery. 3(a): Performing a procedure on tissue below the dermis

NO






• not perform procedure on tissue




• on or below the surface of a tooth or dental implant; and

• not perform surgery. 3(a): Performing a procedure on tissue below the dermis

YES

I/O Device Insertion – Adult and pediatric? Needle decompression during Cardiac Arrest






NO











3(d): Performing a procedure on tissue below the surface of a tooth for the purpose of

• emergency tooth re-implantation

NO

Emergency Tooth Re-implantation -preserving the integrity of the tooth -following protocols developed by an employer





NO






NO




• meet all other practice expectations




and applicable practice directions


NO






NO

Maintenance of established internal esophageal probe Maintenance of established nasogastric tube (non-gravity drain)





NO








NO






YES

Suctioning





NO









NO






NO

Obstetrical Emergencies Related to Prolapsed Umbilical Cord Airway Management of the Fetus During Breech Birth





NO









YES






YES






NO









NO






NO

IV Maintenance





Saline administration

NO

Nebulized treatment








NO

Bag Valve Mask





NO






NO

Eye Irrigation








NO

Wound Irrigation





NO






NO









NO






• Auto-injector • Inhalation,

metered-dose inhaler or nebulizer


• Intranasal

NO




9: If there is a standing order, and with additional training, administering a drug by any method, except vaccines, incidental to the practice of paramedicine ** ** The intention of additional training for this Reserved Act is to ensure pharmacological knowledge rather than

YES

Medication Administration Routes of Administration include Subcutaneous (SC); Intramuscular (IM), Intravenous (IV)




• conduct appropriate monitoring after




knowledge of the route of administration

• medication administration




NO






10(b): Applying electricity

YES

Cardioversion Transcutaneous Cardiac Pacing









NO







NO








NO

Fracture Management To competently and safely manage a fracture with a complication, the Paramedic must:






12: Setting a dislocation of a joint in approved circumstances

YES

Dislocation Management Currently approved circumstances include:

• Interference with extrication

• Interference with Transport

• Distal circulation compromise

To competently and safely manage a dislocation without a complication, the Paramedic must:


• understand the limitations of the approved circumstances




NO





52

Appendix E – Advanced Care Paramedic Scope of Practice


NO










53

2: With additional training, receiving reports of screening or diagnostic tests for the purpose of assessing, diagnosing or resolving a health condition that is appropriate to the paramedic's practice and in accordance with the National Occupational Competency Profile for Paramedics

YES

Tests include: Visualization, Auscultation, Palpation, Thorough history, Pulse, Respirations, Blood Pressure, Temperature, SPO2/ECO2, Blood Glucose, Cardiac monitoring, 12/15 lead acquisition, POCUS, Pulmonary Artery Catheter



• assessment/monitoring of ongoing conditions of clients with chronic illnesses, or


2: With additional training, receiving X-rays, but only for confirmation of device placement

YES

Tracheal intubation Chest tube insertion

To competently and safely perform the receiving of reports of screening or diagnostic tests, the Paramedic must:

• work within the employer’s established policy, procedures, and practice supports to safely manage the receiving and follow-up of results;

• establish efficient and safe processes for response to critical screening and diagnostic test results including any necessary collaboration with other healthcare providers;

• seek information to ensure understanding and necessary follow-up of test results and diagnostic interpretation by specialist(s);



54

• document the reports received and any actions taken based on the results of the report



NO







not perform surgery. 3(a): Performing a procedure on tissue below the dermis

NO








55




NO







NO

Needle Decompression for Tension Pneumothorax







56

3(a): With additional training, performing a procedure on tissue below the dermis

YES

Thoracostomy








YES

Managing Patients with an Established Indwelling Arterial Catheter









57


NO








3(b): Performing a procedure on tissue below the surface of a mucous membrane

YES

Needle (percutaneous) Cricothyroidotomy Surgical Cricothyroidotomy





• not perform procedure on tissue on or below the surface of a tooth for dental implant; and




58

3(d): Performing a procedure on tissue below the surface of a tooth for the purpose of

• emergency tooth re-implantation

NO






NO






-

NO







59


YES

Nasal Tracheal Intubation Insertion of a Device for Epistaxis





NO






NO

Maintenance of established internal esophageal probe Maintenance of established nasogastric tube (non-gravity drain)






60


NO




4(c): With additional training, inserting or removing an instrument or a device beyond the pharynx

YES

Orogastric Tube Insertion and Maintenance





NO







61


NO

Suctioning





NO

Nasogastric Tube Insertion Endotracheal Intubation Forceps Removal of Tracheal Foreign Body





NO







62


NO





4(d): Inserting a device beyond the opening of the urethra

NO

Urinary catheterization

To competently and safely perform a procedure of inserting a device, the Paramedic must:




NO

Obstetrical Emergencies Related to: Prolapsed Umbilical Cord Airway Management of the Fetus During Breech Birth






63


NO

Obstetrical Emergencies Related to: Limb Presentation





NO






YES

Obstetrical Emergencies Related to: Shoulder Dystocia






64

4(e): With additional training, inserting or removing a hand or finger beyond the labia majora

YES

Obstetrical Emergencies Related for the Purpose of Bimanual Compression





NO






NO







65


NO






NO

IV Maintenance





NO

Nebulized treatment






66


NO

Bag Valve Mask





NO






YES

Bi-level Positive Airway Pressure






67


NO

Eye Irrigation





NO

Wound Irrigation





NO







68


NO





5(f): If there is an order specific to the patient from a regulated health professional who is legally permitted and competent to give the order

YES

Administering Blood Products by Transfusion

To competently and safely administer a blood according to this reserved act, the Paramedic must:


• implement safe blood product administration practices (2 person check)



NO







69


• Auto-injector • Inhalation,

metered-dose inhaler or nebulizer


• Intranasal

NO





YES





• conduct appropriate monitoring after medication administration





70


NO






10(a): With additional training, applying point-of-care ultrasound to facilitate intravenous cannulation

YES

Facilitate Intravenous Cannulation

To competently and safely apply ultrasound according to this reserved act, the Paramedic must:




10(a): With additional training, applying point-of-care ultrasound in approved circumstances

YES

There are currently no additional approved circumstances for ACP’s to apply POCUS



71

10(b) Applying or ordering the application of electricity

NO

Cardiac Pacemaker Therapy





NO






NO







72


NO







NO

Fracture Management To competently and safely manage a fracture with a complication, the Paramedic must:




NO

Dislocation Management Currently approved circumstances include:

• Interference with extrication

• Interference with Transport

• Distal circulation compromise

To competently and safely manage a dislocation without a complication, the Paramedic must:


• understand the limitations of the approved circumstances





73


NO







74 Appendix F – CCP Scope of Practice College of Paramedics of Manitoba

Appendix F – Critical Care Paramedic Scope of Practice




No




• assess, discern, plan, implement, and evaluate with the goal of improving client outcomes. • use critical thinking and reasoning skills; and • explain the provisional diagnosis to the individual and support system • meet all other practice expectations and applicable practice directions.

2: With additional training, receiving reports of screening or diagnostic tests for the purpose of assessing, diagnosing or resolving a health condition that is appropriate to the paramedic's practice and in accordance with the National Occupational Competency Profile for Paramedics

YES

Tests include: Visualization, Auscultation, Palpation, Thorough history, Pulse, Respirations, Blood Pressure, Temperature, SPO2/ECO2, Blood Glucose, Cardiac monitoring, 12/15 lead acquisition,

Appropriate and thorough use of assessment skills allows for • confirmation of a diagnosis • assessment/monitoring of ongoing conditions of clients with chronic illnesses, or carrying out screening activities




POCUS, Pulmonary Artery Catheter

2: With additional training, receiving X-rays, but only for confirmation of device placement

YES

Tracheal intubation Chest tube insertion

To competently and safely perform the receiving of reports of screening or diagnostic tests, the Paramedic must: • work within the employer’s established policy, procedures, and practice supports to safely manage the receiving and follow-up of results; • establish efficient and safe processes for response to critical screening and diagnostic test results including any necessary collaboration with other healthcare providers; • seek information to ensure understanding and necessary follow-up of test results and diagnostic interpretation by specialist(s); • document the reports received and any actions taken based on the results of the report • meet all other practice expectations and applicable practice directions.


No


To competently and safely perform a procedure on tissue below the dermis the Paramedic must: • complete additional training for those purposes that require additional training, • meet all other practice expectations and applicable practice directions;




• not suture below the fascia; • not perform procedure on tissue on or below the surface of a tooth or dental implant; and not perform surgery.


No


To competently and safely perform a procedure on tissue below the dermis the Paramedic must: • complete additional training for those purposes that require additional training, • meet all other practice expectations and applicable practice directions; • not suture below the fascia; • not perform procedure on tissue on or below the surface of a tooth or dental implant; and • not perform surgery.


No



• complete additional training for those purposes that require additional training, • meet all other practice expectations and applicable practice directions;






No

Needle Decompression for Tension Pneumothorax


• complete additional training for those purposes that require additional training, • meet all other practice expectations and applicable practice directions;



YES

Thoracostomy


• complete additional training for those purposes that require additional training, • meet all other practice expectations and applicable practice directions; • not suture below the fascia; • not perform procedure on tissue on or below the surface of a tooth or dental implant; and



No

Managing Patients with an Established Indwelling Arterial Catheter






• meet all other practice expectations and applicable practice directions; • not suture below the fascia; • not perform procedure on tissue on or below the surface of a tooth or dental implant; and • not perform surgery.


YES

Arterial Blood Sample Acquisition Umbilical Arterial Cannulation

To competently and safely perform a procedure on tissue below the dermis the Paramedic must: • complete additional training for those purposes that require additional training,



No

Monitoring an Established Pulmonary Artery Catheter and interpreting data, Umbilical Venous Cannulation

To competently and safely perform a procedure on tissue below the dermis the Paramedic must: • complete additional training for those purposes that require additional training,






No


To competently and safely perform a procedure on tissue below the surface of a mucous membrane the Paramedic must: • complete additional training for those purposes that require additional training,


3(b): Performing a procedure on tissue below the surface of a mucous membrane

No

Needle (percutaneous) Cricothyroidotomy Surgical Cricothyroidotomy

To competently and safely perform a procedure on tissue below the surface of a mucous membrane the Paramedic must: • complete additional training for those purposes that require additional training,





3(d): Performing a procedure on tissue below the surface of a tooth

No


To competently and safely perform a procedure on tissue below the surface of a tooth, the Paramedic must: • complete additional training for those purposes that require additional training,



No

Acquisition of Tympanic Temperature Basic Airway Management (NPA)

To competently and safely perform a procedure of inserting or removing an instrument or device, the Paramedic must: • complete additional training for those purposes that require additional training,






No





YES

Nasal Tracheal Intubation Insertion of a Device for Epistaxis




NO


To competently and safely perform a procedure of removing a device, the Paramedic must: • complete additional training for those purposes that require additional training,



Maintenance of established internal esophageal probe

To competently and safely perform a procedure of inserting or removing an




NO

Maintenance of established nasogastric tube (non-gravity drain)

instrument or device, the Paramedic must: • complete additional training for those purposes that require additional training,



NO

BIAD To competently and safely perform a procedure of inserting a device, the Paramedic must: • complete additional training for those purposes that require additional training,


4(c): With additional training, inserting or removing an instrument or a device beyond the pharynx

YES

Orogastric Tube Insertion and Maintenance




No









No

Suctioning




No

Nasogastric Tube Insertion Endotracheal Intubation Forceps Removal of Tracheal Foreign Body



4(c): With additional training, inserting or removing an instrument or device, hand or finger beyond the pharynx

YES

Endotracheal Intubation with Paralytics

To competently and safely perform a procedure of inserting or removing an instrument or device, hand or finger, the Paramedic must:







No





No




4(d): Inserting a device beyond the opening of the urethra

No

Urinary catheterization

To competently and safely perform a procedure of inserting a device, the Paramedic must: • complete additional training for those purposes that require additional training,






No

Obstetrical Emergencies Related to Prolapsed Umbilical Cord Airway Management of the Fetus During Breech Birth

To competently and safely perform a procedure of inserting or removing a hand or finger, the Paramedic must: • complete additional training for those purposes that require additional training,



No





No





No

Obstetrical Emergencies Related to Shoulder Dystocia







4(e): With additional training, inserting or removing a hand or finger beyond the labia majora

YES

Obstetrical Emergencies Related for the Purpose of Bimanual Compression




No





No








No





No

IV Maintenance

To competently and safely administer a substance according to this reserved act, the Paramedic must: • complete additional training for those purposes that require additional training • receive a standing order where required • meet all other practice expectations and applicable practice directions.


No

Nebulized treatment

To competently and safely administer a substance according to this reserved act, the Paramedic must: • complete additional training for those purposes that require additional training • receive a standing order where required






No

Bag Valve Mask


• complete additional training for those purposes that require additional training • receive a standing order where required • meet all other practice expectations and applicable practice directions.


No





No

Bi-level Positive Airway Pressure






• receive a standing order where required • meet all other practice expectations and applicable practice directions.


No

Eye Irrigation




No

Wound Irrigation




No








No




5(f): If there is an order specific to the patient from a regulated health professional who is legally permitted and competent to give the order

No

Administering Blood Products by Transfusion

To competently and safely administer a blood according to this reserved act, the Paramedic must: • complete additional training for those purposes that require additional training • implement safe blood product administration practices (2 person check) • meet all other practice expectations and applicable practice directions.


No


To competently and safely administer oxygen according to




this reserved act, the Paramedic must: • complete additional training for those purposes that require additional training • meet all other practice expectations and applicable practice directions.

9: If there is a standing order, and with additional training, administering a drug, except vaccines, by • Auto-injector • Inhalation, metered-dose inhaler or nebulizer • Buccal, oral or sublingual routes • Intranasal

No


To competently and safely administer a drug according to this reserved act, the Paramedic must: • meet all other practice expectations and applicable practice directions. • meet all other practice expectations and applicable practice directions.


YES


To competently and safely administer a drug according to this reserved act, the Paramedic must: • complete additional training for those purposes that require additional training • understand indications and contraindications for all medications • conduct appropriate monitoring after medication administration • Document all medications given • meet all other practice expectations and applicable practice directions.

9: Administering a vaccine by any method in accordance


To competently and safely administer a drug according to




with provincial requirements if the vaccine is required as part of a communicable disease response or in a public health emergency

No

this reserved act, the Paramedic must: • complete additional training for those purposes that require additional training • understand the provincial requirements and protocols • meet all other practice expectations and applicable practice directions.

10(a): With additional training, applying point-of-care ultrasound

YES

Facilitate Intravenous Cannulation

To competently and safely apply ultrasound according to this reserved act, the Paramedic must: • complete additional training for those purposes that require additional training • receive a standing order where required • meet all other practice expectations and applicable practice directions.

10(a): With additional training, applying point-of-care ultrasound in approved circumstances

YES

Intra-abdominal Free Fluid or Blood Pericardial Fluid or Blood Organized Cardiac Contractile Activity Abdominal Aneurysm Pneumothorax Pleural Fluid or Blood

To competently and safely apply ultrasound according to this reserved act, the Paramedic must: • complete additional training for those purposes that require additional training • receive a standing order where required • meet all other practice expectations and applicable practice directions.




10(b) Applying or ordering the application of electricity

No

Cardiac Pacemaker Therapy

To competently and safely apply electricity according to this reserved act, the Paramedic must: • complete additional training for those purposes that require additional training • receive a standing order where required • meet all other practice expectations and applicable practice directions.


No



10(b) Applying electricity for automated or semi-automated defibrillation without rhythm interpretation

No



10(b) Applying electricity No


To competently and safely apply electricity according to this




reserved act, the Paramedic must: • complete additional training for those purposes that require additional training • receive a standing order where required • meet all other practice expectations and applicable practice directions.

12: Setting a fracture of a bone for the purpose of • restoring perfusion, • extrication • immobilization

No

Fracture Management To competently and safely manage a fracture with a complication, the Paramedic must: • complete additional training for those purposes that require additional training • receive a standing order where required • meet all other practice expectations and applicable practice directions.


No

Dislocation Management

Currently approved circumstances include: • Interference with extrication • Interference with Transport • Distal circulation compromise

To competently and safely manage a dislocation without a complication, the Paramedic must: • complete additional training for those purposes that require additional training • understand the limitations of the approved circumstances • receive a standing order where required • meet all other practice expectations and applicable practice directions.





No

Prehospital Delivery To competently and safely manage the labor and delivery of a baby, the Paramedic must: • complete additional education for those purposes indicated above that require additional education • collaborate with other health-care providers as necessary • meet all other practice expectations and applicable practice directions

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