Demography of the National Emergency Medical Services Workforce: A Description of Those Providing Patient Care in the Prehospital Setting

Abstract

Background: The emergency medical services (EMS) workforce is a key component of healthcare in the U.S. Characteristics of active EMS professionals who are treating patients in the prehospital setting is unclear. The purpose of this study was to describe the roles and settings in which nationally certified EMS professionals are providing patient care and to evaluate similarities and differences of the demographics and practice settings of the three major certification levels.
Methods: We conducted a cross-sectional evaluation of all nationally certified EMS professionals in the U.S. that recertified between October 1, 2017 and March 31, 2018 and October 1, 2018 and March 31, 2019. Within the recertification application, EMS professionals completed an optional demographic profile. Those who were nationally certified, functioning as a patient care provider for at least one non-military EMS organization, aged 18 to 85 years, and recertified at the EMT level or higher were included. Demographic, agency and job characteristics were assessed and descriptive statistics were calculated.
Results: In 2017-2018, 101,363 EMS professionals recertified and 87,471 (86%) completed the profile; in 2018-2019, 106,893 EMS professionals recertified and 92,640 (87%) completed the profile. Of the 142,751 EMS professionals who met inclusion criteria, the population was primarily male (76%) and age increased by certification level. By race/ethnicity, 85% were white, 5% were Hispanic/Latino, 5% were Black/African American, 2% were American Indian/Alaskan Native, 2% were Asian and 1% were Native Hawaiian/Pacific Islander.
Paramedics had the highest proportion of associate degrees (EMT:16.0%; AEMT:16.6%; paramedic:28.5%); some college experience was common for all certification levels (EMT:34.7%; AEMT:37.2%; paramedic:31.6%). Most EMS professionals reported 3-7 years of experience, were working full-time (78%) and 28% were working for 2 or more agencies. Most were working for a fire department (48%) or private agency (21%) and providing 9-1-1 service (72%). No substantial differences were observed between the two recertification cycles.
Conclusion: This is the most comprehensive study evaluating the demographics of the national EMS workforce of active patient care providers. Understanding the characteristics of EMS professionals and the settings they practice in is important for educational and training initiatives, as well as protocols and policies.

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Demography of the National Emergency Medical
Services Workforce: A Description of Those
Providing Patient Care in the Prehospital Setting
Madison K. Rivard, Rebecca E. Cash, Christopher B. Mercer, Kirsten Chrzan &
Ashish R. Panchal
To cite this article: Madison K. Rivard, Rebecca E. Cash, Christopher B. Mercer, Kirsten Chrzan
& Ashish R. Panchal (2020): Demography of the National Emergency Medical Services Workforce:
A Description of Those Providing Patient Care in the Prehospital Setting, Prehospital Emergency
Care, DOI: 10.1080/10903127.2020.1737282
To link to this article: https://doi.org/10.1080/10903127.2020.1737282
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DEMOGRAPHY OF THE NATIONAL EMERGENCY MEDICAL SERVICES WORKFORCE:
AD
ESCRIPTION OF THOSE PROVIDING PATIENT CARE IN THE
PREHOSPITAL SETTING
Madison K. Rivard, MPH, NREMT , Rebecca E. Cash, PhD, MPH, NRP ,
Christopher B. Mercer, DC, MPAS, Kirsten Chrzan, MPH, NREMT,
Ashish R. Panchal, MD, PhD
ABSTRACT
Background: The emergency medical services (EMS)
workforce is a key component of healthcare in the U.S.
Characteristics of active EMS professionals who are treat-
ing patients in the prehospital setting is unclear. The pur-
pose of this study was to describe the roles and settings
in which nationally certified EMS professionals are pro-
viding patient care and to evaluate similarities and differ-
ences of the demographics and practice settings of the
three major certification levels. Methods: We conducted a
cross-sectional evaluation of all nationally certified EMS
professionals in the U.S. that recertified between October
1, 2017 and March 31, 2018 and October 1, 2018 and
March 31, 2019. Within the recertification application,
EMS professionals completed an optional demographic
profile. Those who were nationally certified, functioning
as a patient care provider for at least one nonmilitary
EMS organization, aged 18 to 85 years, and recertified at
the EMT level or higher were included. Demographic,
agency and job characteristics were assessed and descrip-
tive statistics were calculated. Results: In 2017-2018,
101,363 EMS professionals recertified and 87,471 (86%)
completed the profile; in 2018-2019, 106,893 EMS profes-
sionals recertified and 92,640 (87%) completed the profile.
Of the 142,751 EMS professionals who met inclusion crite-
ria, the population was primarily male (76%) and age
increased by certification level. By race/ethnicity, 85%
were white, 5% were Hispanic/Latino, 5% were Black/
African American, 2% were American Indian/Alaskan
Native, 2% were Asian and 1% were Native Hawaiian/
Pacific Islander. Paramedics had the highest proportion of
associate degrees (EMT:16.0%; AEMT:16.6%; para-
medic:28.5%); some college experience was common for
all certification levels (EMT:34.7%; AEMT:37.2%; para-
medic:31.6%). Most EMS professionals reported 3-7 years
of experience, were working full-time (78%) and 28%
were working for 2 or more agencies. Most were working
for a fire department (48%) or private agency (21%) and
providing 9-1-1 service (72%). No substantial differences
were observed between the two recertification cycles.
Conclusion: This is the most comprehensive study
evaluating the demographics of the national EMS work-
force of active patient care providers. Understanding the
characteristics of EMS professionals and the settings they
practice in is important for educational and training initia-
tives, as well as protocols and policies. Key words:
emergency medical services; workforce; demography
PREHOSPITAL EMERGENCY CARE 2020;00:000–000
INTRODUCTION
Emergency medical services (EMS) play a key role in
the provision of healthcare across the United States
by providing patient care in the prehospital setting.
The field of EMS was developed in the 1960s due to
the incidence of traffic incidents and has continued to
evolve (1). As there were more than 20 million EMS
activations between 2012 and 2016, this is an active
workforce who are treating both acute injuries and
chronic diseases (2,3). EMS often serves communities
in the intersection of healthcare, public health, and
public safety. EMS is a common entry point into the
healthcare continuum and as such, the professionals
who make up this workforce and provide necessary
medical care in the prehospital setting are an import-
ant workforce to better understand (4). Additionally,
there is also a need to define the practice settings (e.g.
type of agency and level of service) in which EMS
professionals are working in. As EMS professionals
are providing patient care every day in the prehospi-
tal setting throughout the United States, there should
Received February 10, 2020 from National Registry of Emergency
Medical Technicians, Columbus, OH, USA (MKR, CBM, KC, ARP);
Department of Emergency Medicine, Massachusetts General
Hospital, Boston, MA, USA (REC); Division of Epidemiology, The
Ohio State University College of Public Health, Columbus, OH, USA
(KC, ARP); Department of Emergency Medicine, Wexner Medical
Center, The Ohio State University, Columbus, OH, USA (ARP).
Revision received February 25, 2020; accepted for publication
February 26, 2020.
No potential conflict of interest was reported by the author(s).
Prior presentations: An abstract of this work was presented at
the 2019 National Association of Emergency Medical Services
Physicians Annual Meeting, January 2019, Austin TX.
Address correspondence to Madison K. Rivard, National
Registry of Emergency Medical Technicians, 6610 Busch Blvd,
Columbus, OH 43229, USA. E-mail: rivard.18@osu.edu
ß2020 National Association of EMS Physicians
doi:10.1080/10903127.2020.1737282
1

be further research into the demographic and job
characteristics of this population.
Previous estimates have shown that the EMS pro-
fessionals who make up the EMS workforce tend to
be younger than other health care providers, with
an average age of 35 (4,5). Less than a third of the
workforce has been reported as female in previous
studies, and the majority have been of white non-
Hispanic race and ethnicity. While these studies
have been beneficial for describing the EMS work-
force, they are not without limitations in their meth-
ods and findings. Past studies on the workforce as a
whole have not separated the descriptions by certifi-
cation level, often grouping emergency medical
technicians (EMTs) and paramedics together for
analysis (4). These two levels have very different
scopes of practice as well as education and training
requirements, therefore these generalized results
may not be applicable to each of the certification
levels. Furthermore, previous findings have not
necessarily captured the active workforce of people
who are currently providing patient care in the pre-
hospital setting (4). Some EMS professionals who
hold national certification may be working in an
administration or training position and may not be
providing patient care. Ultimately there have been
few national descriptions of the EMS workforce that
accurately describe the characteristics of the active
EMS workforce.
As the need for emergency medical services
increases and EMS patient care providers continue to
provide a key service to communities all around the
United States, it is beneficial to understand the charac-
teristics of the EMS workforce, identify trends in staff-
ing and shortages, and monitor the need and ability
to meet surge capacity both locally and nationally. A
current and accurate analysis of the national EMS
population is needed in order to support efforts to
maintain and support the strength and stability of the
EMS workforce. Our objectives were 1) to describe the
characteristics and settings in which nationally certi-
fied EMS personnel at the three main certification lev-
els are providing patient care; and 2) to assess the
feasibility of using the recertification population as a
random sample of nationally certified EMS professio-
nals for research purposes.
METHODS
Study Population, Setting and Design
This was a cross-sectional evaluation of nationally certi-
fied EMS professionals in the United States who recerti-
fied their National EMS Certification between October
1
st
, 2017 to March 31, 2018 or October 1, 2018 to March
31
st
, 2019. There are four levels of National EMS
Certification, provided by the National Registry of
Emergency Medical Technicians, that comprise the
workforce: emergency medical responder (EMR), emer-
gency medical technician (EMT), advanced EMT
(AEMT) and paramedic (6). National certification is
required for initial licensure at one or more certification
level for more than 46 states, territories, and federal
agencies (7). Continuous certification, including biennial
recertification, is voluntary; however, ten states require
National EMS Certification to maintain state EMS licen-
sure at one or more certification levels. These
“recertification states”include Alabama, Louisiana,
Massachusetts, Minnesota, New Hampshire, North
Dakota, South Carolina, Vermont, West Virginia, and
Utah. The National EMS Certification database contains
a list of essentially all EMS professionals within these
states who are certified and licensed.
This study included EMS professionals who recer-
tified their National EMS Certification during the
two most recent recertification cycles (“Cohort
One”: 2017-2018 and “Cohort Two”: 2018-2019). As
part of the recertification process, demographic and
EMS characteristic data were collected from recerti-
fication applications along with an optional work-
force profile within the application that EMS
professionals submitted. EMTs, AEMTs and para-
medics submitted recertification applications during
Cohort One and Cohort Two and were included in
the analysis; the recertification process for EMRs dif-
fered from the other certification levels and thus
EMRs were excluded.
The primary focus of this study was EMS profes-
sionals who were currently providing patient care
in the prehospital setting. We defined the active
patient care EMS workforce as those who were
nationally certified and providing patient care for at
least one nonmilitary EMS organization or agency,
aged 18 to 85 years, and recertified at the EMT level
or higher. Through the profile, if the participant
was functioning as a patient care provider during a
typical week at their main EMS job, then they were
identified as an EMS patient care provider and thus
included. The American Institutes for Research
Institutional Review Board approved this study, and
a waiver of consent was granted.
Measures
Data were collected from the National EMS
Certification database regarding the demographics of
nationally certified EMS patient care providers
including sex, age, race/ethnicity and education level.
The nominal variable of sex was categorically desig-
nated as male or female. Age was analyzed as a con-
tinuous variable. Due to the small proportion of
2PREHOSPITAL EMERGENCY CARE 䊏/䊏2020 VOLUME 0/NUMBER 0

minority EMS professionals, race and ethnicity were
dichotomized to non-minority (white, non-Hispanic)
or minority. The minority category included any per-
son who self-identified as Black or African American,
Asian, Hispanic or Latino, or Native Hawaiian or
Pacific Islander. Education level was categorized as
high school, GED or less; some college experience;
associate degree; bachelor’s degree or more.
The workforce profile included questions about
job characteristics for their role in EMS and ques-
tions about their main EMS agency (8). The profile
contained items assessing the number of EMS jobs
held (1 job/2 or more jobs), if the participant func-
tioned as a patient care provider during a typical
week (yes/no) and the primary role at their main
EMS job. The main EMS job was defined as the
agency for which someone did most of their EMS
work. For the main EMS job, we asked about the
agency type, service type, employment status (full-
time/part-time), years of experience at their main
EMS agency (2 years or less; 3-7 years; 8-15 years;
16 years or more), and urbanicity (urban/rural).
Definitions for each choice (e.g., what was
considered a fire-based agency) were included in
the profile for clarification (8).
Analysis
Descriptive statistics were calculated on the demo-
graphics of all currently nationally certified EMS
patient care providers in Cohort One and Cohort
Two combined. All analyses were completed using
STATA IC version 16 (StataCorp LP, College
Station, TX).
RESULTS
In Cohort One, 101,363 people recertified and 87,471
(86%) completed the workforce profile (Table 1). In
Cohort Two 106,893 people recertified, and 92,640
(87%) EMS professionals completed the workforce
profile. Over the two recertification cycles, a total of
180,111 EMS professionals completed the profile
and 142,751 met the criteria as active patient care
providers. Of those who completed the profile,
65,505 were excluded from the analysis for the
TABLE 1. The overall characteristics of the sample population, and characteristics of Cohort One and Cohort Two
Characteristic
Overall
N¼142,751
n (%)
Cohort One (2017-2018)
(N ¼69,422)
n (%)
Cohort Two (2018-2019)
(N ¼73,329)
n (%)
Sex
Female 34,340 (24.2) 16,446 (24.2) 17,894 (24.5)
Male 107,638 (75.8) 52,621 (75.8) 55,017 (75.5)
Missing 773 355 418
Age - mean (SD) 38 (10.9) 38 (10.9) 38 (10.8)
Race/Ethnicity
White 117,672 (84.94) 57,659 (85.60) 60,013 (84.30)
Asian 2,315 (1.67) 1,044 (1.55) 1,271 (1.79)
Black or African American 6,590 (4.76) 3,029 (4.50) 3,561 (5.00)
Hispanic or Latino 7,599 (5.48) 3,476 (5.16) 4,123 (5.79)
American Indian or Alaskan Native 2,992 (2.16) 1,469 (2.18) 1,523 (2.14)
Native Hawaiian or other Pacific Islander 1,375 (0.99) 679 (1.01) 696 (0.98)
Missing 4,208 2,066 2,142
Education Level
HS/GED or less 26,175 (18.3) 13,242 (19.1) 12,933 (17.6)
Some college 47,740 (33.4) 22,671 (32.7) 25,069 (34.2)
Associates degree 30,862 (21.6) 15,193 (21.9) 15.669 (21.4)
Bachelor’s degree or more 37,957 (26.6) 18,307 (26.4) 19,650 (26.8)
Missing 17 9 8
Years of Experience at Main EMS job
2 years or less 40,388 (28.4) 19,259 (27.7) 23,441 (27.6)
3-7 years 43,193 (30.3) 20,646 (29.7) 26,163 (30.8)
8-15 years 33,189 (23.3) 16,570 (23.9) 19,753 (23.2)
16þyears 25,621 (18.0) 12,770 (18.4) 15,661 (18.4)
Missing 360 177 183
Full Time 109,784 (77.6) 53,207 (77.4) 56,577 (77.8)
Missing 1,309 660 649
Number of Organizations
1 102,887 (72.1) 49,831 (71.8) 53,056 (72.4)
2 or more 39,864 (27.9) 19,591 (28.2) 20,273 (27.7)
M. K. Rivard et al. DEMOGRAPHY OF EMS WORKFORCE 3

TABLE 2. Demographic characteristics of nationally certified patient care EMS professionals overall and
by certification level
Characteristic
Overall N ¼142,751
n (%)
EMTs
N¼71,593
n (%)
AEMTs
N¼7,043
n (%)
Paramedic
N¼64,115
n (%)
Sex
Female 34,340 (24.2) 18,981 (26.7) 1,828 (26.1) 13,531 (21.2)
Male 107,638 (75.8) 52,125 (73.3) 5,177 (73.9) 50,336 (78.8)
Missing 773 487 38 248
Age - mean (SD) 38 (10.9) 36 (11.5) 37 (10.9) 39 (9.9)
Minority Status
Non-Hispanic White 117,672 (82.4) 56,712 (81.7) 5,834 (85.3) 55,126 (88.5)
Minority 20,871 (14.6) 12,703 (18.3) 1,008 (14.7) 7,160 (11.5)
Missing 4,208 2,178 201 1,829
Education Level
HS/GED or less 26,175 (18.3) 16,057 (22.4) 1,522 (21.6) 8,596 (13.4)
Some college 47,740 (33.4) 24,839 (34.7) 2,619 (37.2) 20,282 (31.6)
Associates degree 30,862 (21.6) 11,432 (16.0) 1,170 (16.6) 18,260 (28.5)
Bachelor’s degree or more 37,957 (26.6) 19,259 (26.9) 1,730 (24.6) 16,968 (26.5)
Missing 17 6 2 9
Abbreviations: SD –standard deviation, HS –high school; GED –general education diploma; EMT –emergency medical technician; AEMT –
advanced emergency medical technician.
TABLE 3. Job and agency characteristics of EMS patient care providers, overall and by certification level
Characteristic
Overall N ¼142,751
n (%)
EMTs
N¼71,593
n (%)
AEMTs
N¼7,043
n (%)
Paramedic
N¼64,115
n (%)
Years of Experience at main EMS job
2 years or less 40,388 (28.4) 24,599 (34.4) 1,861 (26.5) 13,928 (21.8)
3-7 years 43,193 (30.3) 21,230 (29.7) 2,514 (35.8) 19,449 (30.4)
8-15 years 33,189 (23.3) 14,282 (20.0) 1,661 (23.6) 17,246 (27.0)
16þyears 25,621 (18.0) 11,293 (15.8) 994 (14.1) 13,334 (20.9)
Missing 360 189 13 158
Full Time 109,784 (77.6) 48,325 (68.3) 5,256 (75.2) 56,203 (88.3)
Missing 1,309 813 57 439
Number of Organizations
1 102,887 (72.1) 55,776 (77.9) 4,764 (67.6) 42,347 (66.0)
2 or more 39,864 (27.9) 15,817 (22.1) 2,279 (32.4) 21,768 (34.0)
Main Agency
Fire Department 68,680 (48.3) 36,626 (51.4) 3,636 (51.7) 28,418 (44.4)
Private 30,204 (21.2) 15,261 (21.4) 1,507 (21.4) 13,436 (21.0)
Governmental Non-Fire 17,159 (12.1) 7,504 (10.5) 902 (12.8) 8,753 (13.7)
Hospital 15,363 (10.8) 6,515 (9.1) 665 (9.5) 8,183 (12.8)
Other6,769 (4.8) 4,668 (6.6) 300 (4.3) 1,801 (2.8)
Air Medical 4,070 (2.9) 662 (0.9) 18 (0.3) 3,390 (5.3)
Missing 506 357 15 134
Service Type
Primarily 9-1-1 101,966 (71.8) 50,486 (70.9) 5,400 (77.0) 46,080 (72.2)
Combination of 9-1-1 & medical transport 20,368 (14.3) 9,160 (12.9) 925 (13.2) 10,283 (16.1)
Primarily Medical Transport (convalescent) 7,395 (5.2) 4,376 (6.1) 273 (3.9) 2,746 (4.3)
Clinical Services 6,109 (4.3) 3,498 (4.9) 222 (3.2) 2,389 (3.7)
Other 5,595 (3.9) 3,344 (4.7) 173 (2.5) 2,078 (3.2)
Mobile Integrated Health/Community Paramedicine 630 (0.4) 325 (0.5) 22 (0.3) 283 (0.4)
Missing 688 404 28 256
Community Size
Rural (<25,000 people) 49,253 (35.8) 29,010 (42.1) 2,996 (44.3) 17,247 (27.9)
Urban (25,000 people) 88,207 (64.2) 39,850 (57.9) 3,766 (55.7) 44,591 (72.1)
Missing 5,291 2,733 281 2,277
Abbreviations: EMT –emergency medical technician; AEMT –advanced emergency medical technician.
Other agency types include tribal, volunteer, rescue squad, ski patrol, and write-in option.
Other service types include write-in option.
4PREHOSPITAL EMERGENCY CARE 䊏/䊏2020 VOLUME 0/NUMBER 0

following reasons: aged under 18 or over 85 years
(n ¼49), not currently working (n ¼13,380), not pro-
viding patient care (n ¼15,180), or working in a
military setting (n ¼10,760). Some individuals were
excluded for multiple criteria. The cohorts have
been combined to capture a complete description of
the active EMS workforce providing patient care.
For the racial and ethnic demographics of this popu-
lation, 84.94% were white, 5.48% were Hispanic or
Latino, 4.76% were Black or African American,
2.16% were American Indian or Alaskan Native,
1.67% were Asian and 0.99% were Native Hawaiian
or other Pacific Islander (Table 1).
Overall, 90.9% of the nationally certified popula-
tion was functioning as a patient care provider dur-
ing a typical week. The sample was primarily male
(75.8%) and non-Hispanic white (82.4%) with a
mean age of 38 years (Table 2). These characteristics
were similar across the certification levels, but age
increased with certification level. Paramedics had
the highest proportion of associate degrees (28.5%)
compared to EMTs and AEMTs (16.0% and 16.6%,
respectively), but some college experience was the
most predominant amount of education reported for
all certification levels (EMT: 34.7%; AEMT: 37.2%;
paramedic: 31.6%).
Tenure at their main EMS job was low, with most
reporting 3-7 years of experience (EMT: 29.7%;
AEMT: 35.8%; paramedic: 30.4%). (Table 3). By certi-
fication level, over one third of EMTs had worked
for their current EMS agency for 2 years or less
(34.4%). Paramedics had the most years of service at
their current agency with 20.9% reporting 16 or
more years. Overall, the majority of EMS patient
care providers were working full-time in EMS
(77.6%); 88.3% of paramedics reported full-time
EMS employment, compared to 68.3% of EMTs and
75.2% of AEMTs. More than one-quarter of the
workforce reported holding multiple EMS jobs
(27.9%). By certification level, paramedics were
working the most for 2 or more organizations
(34.0%) compared to EMTs (22.1%) and AEMTs
(32.4%). Most EMS professionals were working for a
fire department (48.3%) or a private agency (21.2%);
the third most common was governmental non-fire
agencies (12.1%). These agency characteristics were
FIGURE 1. Number of nationally certified EMS patient care providers in each state. Recertification states are outlined in bold.
A total of 1,390 people did not have a mailing address included with their recertification application, and therefore were not included in the analysis.
M. K. Rivard et al. DEMOGRAPHY OF EMS WORKFORCE 5

common across all three certification levels. Overall,
the most common service type was primarily 9-1-1
(71.8%) which was consistent across the certification
levels. While about two-thirds of the EMS workforce
worked in urban settings, 72.1% of paramedics
worked for urban communities which was propor-
tionally more than both EMTs and AEMTs (57.9%
and 55.7% respectively).
Figure 1 shows the geographic spread of the num-
ber of nationally certified EMS professionals provid-
ing patient care across the United States. For the ten
states that are marked in bold as recertification
states, this is expected to be the complete number of
the active EMS patient care providers in the state.
The state with the most national certified EMS
patient care providers was Alabama with 8,302 peo-
ple, while Wyoming had the least (n ¼415).
DISCUSSION
The findings from this study serve to reinforce conclu-
sions from previous research, as well as highlight
new information about the active EMS workforce. In
this evaluation of the nationally-certified EMS popu-
lation, over 90% of active EMS professionals were
providing patient care in a typical week. As has been
shown in prior studies of EMS professionals, the
patient care providers were primarily male and white
(9). A significant proportion of these EMS providers
were working more than one job, which echoes this
phenomenon seen in other workforce studies (10).
Most EMS providers were working full-time, and the
majority of the EMS population is working for fire
departments or private agencies, and providing 9-1-1
service to urban communities. Within the nationally
certified EMS population, most EMS professionals are
providing patient care, and demographically are simi-
lar to previous studies. Additionally, this study has
shown that the recertification population is an appro-
priate, representative sample of the nationally certi-
fied population, thus paving the way for use of this
database in future research.
While just under half of the population was work-
ing primarily for a fire department, this signifies
that half of the nationally certified EMS population
that is providing patient care works outside of a
fire-based agency. Typically, EMS is closely associ-
ated to fire departments; however, this study illus-
trates that there are many other settings in which
EMS providers are providing patient care (4). We
also found that a third of the nationally certified
EMS population provides an EMS service other than
primarily 9-1-1 response. These findings challenge
the common assumptions and paradigm of what is
typically considered the EMS workforce.
There were notable differences in characteristics
between the three certification levels. The levels of
education and training increase from EMT to para-
medic, and the provision of care between certifica-
tion levels have different scopes of practice and skill
settings (6,11). We found that most EMTs were new
to their main agency in EMS, demonstrating that a
bulk of the workforce was inexperienced in their
current position. Because paramedic certification
requires more time to complete, the longer duration
of service for this level was expected. These findings
align with previous studies that have identified that
turnover is a concern within the EMS community
(12–15). Even if EMS providers continue practicing
patient care in the profession, turnover between
EMS jobs or agencies could still have a negative
impact on the workforce and provision of EMS care.
Protocols, policies and terminology often vary
between EMS agencies, even within the same state,
therefore patient care providers in EMS may still
need to undergo training and onboarding within
each job position. Further research is needed to
identify the true estimates and impact of turnover
between job positions within the EMS field.
Across all certification levels, a significant propor-
tion of EMS patient care providers were currently
working for two or more EMS organizations. This
finding echoes previous work that indicates that
EMS patient care providers are often working mul-
tiple jobs (10). Identifying how many of these indi-
viduals are working part-time or multiple jobs in
EMS is a measure of the availability and capacity of
the workforce. The accurate number of trained pro-
fessionals available to respond in times of major
incidents may be overestimated; at surge capacity,
EMS professionals who take care of patients would
only be available to respond for one agency. Use of
EMS agency rosters alone may overestimate the true
number of people who would be able to provide
EMS care in the time of a mass emergency.
Methodologically, the recertification population
provides an opportunity to enumerate and study the
active EMS workforce. Defining the EMS workforce
has been challenging due to a lack of consistent defin-
ition and tracking of those providing EMS care across
the country (16). Unlike physicians, who are tracked
in a centralized database across the United States
regardless of practice setting, EMS professionals with-
out national certification are challenging to enumerate
(17). The National EMS Certification database is cur-
rently the best proxy for those working in EMS, espe-
cially among states that require continued national
certification. This population should be leveraged to
further understand the epidemiology and characteris-
tics of the EMS workforce.
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Additionally, we found that the characteristics of
each recertification cohort were essentially equiva-
lent, demonstrating that a single recertification cohort
represents a random sample of the nationally certified
EMS workforce. This finding illustrates that the recer-
tification population is a sufficient and available sam-
ple to use in future evaluations to identify other
characteristics of the EMS workforce. Evaluating the
population of nationally certified EMS patient care
providers allows for a current description at the
workforce and identifies the EMS professionals who
are practicing in the prehospital setting.
There have been studies on the clinical aspects of
emergency medical services (2) or that have eval-
uated the demographic characteristics of the EMS
population (18). However, this is the most compre-
hensive and up-to-date national study on the epi-
demiology of the workforce of EMS professionals
who are providing patient care across the United
States. Additionally, previous studies describing the
EMS workforce have had challenges of response
rates. The methodology we used in this study to
assimilate the profile with the biannual recertifica-
tion process was able to capture the largest popula-
tion of EMS patient care providers at a
national level.
A further challenge in conducting EMS research is
the lack of standardized terminology within the
community. Regionally, from state to state, between
National Association of State EMS Officials
(NASEMSO) regions and even from one agency to
another, the terminology for agency and service
type, especially, are highly variable in the EMS com-
munity (4,16). For example, the common agency
type of “governmental, non-fire”may also be called
county, city, third service, municipal, or rescue
squad. These variations illustrate the lack of a stand-
ardization across the United States to define the
practice settings within EMS, which in turn creates
a challenge to describing the workforce.
This study has several limitations. We used the
population of nationally certified EMS professionals
who were currently working and providing care;
however, this sample may not be generalizable to
all EMS professionals in the United States. We were
unable to capture EMS professionals who were state
licensed only, had just entered the workforce
through initial certification, or who chose not to
recertify their National EMS Certification. The non-
nationally certified population has been shown to be
older and have more years of experience than the
nationally certified population (18). EMS professio-
nals that chose not to recertify might have stopped
working in EMS, therefore letting their certification
lapse, or were no longer nationally certified but still
working with a state license.
The variation in terminology may have resulted
in misclassification, such as the types of agencies
and services for which those in EMS reported work-
ing. This analysis was also only able to identify the
characteristics of these EMS patient care providers
at a single point in time. EMS professionals may
move between different jobs, agencies, or even
states. Future longitudinal research is encouraged to
identify trends in the work characteristics of the
EMS workforce.
CONCLUSION
This was the most comprehensive and up-to-date
national study evaluating the demographics of the
individual, as well as the job characteristics and set-
tings were EMS professionals who were providing
patient care. We identified that a substantial propor-
tion of the EMS workforce was not working in the
fire-based/non-governmental settings that are typic-
ally attributed to EMS. Our understanding of the
patient care providers that make up the EMS work-
force and the settings in which they practice is
important for educational and training initiatives, as
well as protocols and policies. A national descrip-
tion of the job positions, agencies and practice set-
tings in which EMTs, AEMTs and paramedics are
working is a critical first step to better understand-
ing the EMS workforce of the United States.
ORCID
Madison K. Rivard http://orcid.org/0000-0002-
7961-6638
Rebecca E. Cash http://orcid.org/0000-0002-
0355-1014
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