Emergency medical services in New Zealand

Since the age of the motor vehicle many Hospital Boards ran their own services. From 1957 to 1990 the Hospital Act stipulated that Hospital Boards had to provide an ambulance service. Many contracted that out to St John or had ad hoc arrangements with them, often for after hours staffing. When the Hospital Act was replaced by Health Boards, many of these Boards saw this as a chance to avoid being responsible and subsequently St John took over from many Boards (e.g. Thames, Bay of Plenty, Wanganui, Palmerston North, Waipawa, Dannevirke, Nelson, West Coast, Ashburton, Southland). Marlborough stayed a Hospital-based service until 2007 and Taranaki until 2011. Wairarapa was the last region with a hospital-based service, ceasing in March 2012 and being taken over by Wellington Free Ambulance.{{cite web|url=http://www.times-age.co.nz/news/free-service-steps-in/1218393/|title=Free service steps in|publisher=Wairarapa Times Age|date=23 December 2011|access-date=14 March 2012|archive-url=https://web.archive.org/web/20120214075810/http://www.times-age.co.nz/news/free-service-steps-in/1218393/|archive-date=14 February 2012|url-status=dead|df=dmy-all}}

While both land ambulance service providers do have paid staff, they also rely very heavily on volunteer members. In most cases, paid staff tend to be concentrated in urban areas and in the management of rural areas, with rural response staff being largely volunteer-based. St. John Ambulance reports a total of 2,211 paid staff in New Zealand, supplemented by 7,647 volunteers.{{cite web|url=http://www.stjohn.org.nz/about/facts.aspx|title=St John Ambulance National Performance Statistics (1)(website)|access-date=9 February 2009}} By contrast, Wellington Free Ambulance currently staffs 108 paid paramedics and 35 volunteers, not including the 21 paid staff and 21 auxiliary (volunteer) staff previously from the Wairarapa DHB service.

St. John provides service to approximately 88 percent of the population of New Zealand and 17 district health boards (DHBs), through a network of 553 ambulances and 183 ambulance stations.{{cite web|url=http://www.stjohn.org.nz/about/facts.aspx|title=St John Ambulance National Performance Statistics (2)(website)|access-date=9 February 2009}} St. John Ambulance reports the completion of approximately 274,108 emergency responses for the year ending 1 July 2008.{{cite web|url=http://www.stjohn.org.nz/about/facts.aspx|title=St John Ambulance National Performance Statistics (3)(website)|access-date=9 February 2009}} By contrast, Wellington Free Ambulance provides service to 12 percent of the population of New Zealand and three district health boards (Capital & Coast, Hutt Valley and Wairarapa), providing service to more than 500,000 residents. They respond to an estimated 40,000 calls per year.{{cite web|url=http://www.wfa.org.nz/Services.htm |title=Services We Provide (WFA Official website) |access-date=9 February 2009 |url-status=dead |archive-url=https://web.archive.org/web/20081014071941/http://www.wfa.org.nz/Services.htm |archive-date=14 October 2008 }}

{{cite web|url=http://www.111.govt.nz/technology/no_of_calls_ambulance.html|title=Ambulance Communications Centres Today|publisher=NZ Government 111 website|access-date=20 February 2009}}

File:St John Emergency Vehicles Auckland.jpg|Ambulance station in Auckland

File:St John Ambulance 274.JPG|St John Ambulance 274

File:Wellington_Free_Ambulance_430.jpg|Wellington Free Ambulance at Lower Hutt Ambulance Station

File:WFA Ambulance 429.JPG|Wellington Free Ambulance Patient Transfer 429

File:Westpac Rescue Helicopter 2009 RNZAF Base Whenuapai Air Show.jpg

File:Otago Rescue Helicopter Dunedin Public Hospital.ogv

File:ZK-LFW.JPG]]

Air ambulance and helicopter rescue services are vital given the low population density of New Zealand and the significant distances between tertiary hospitals. There are three organisations contracted to operate air ambulance helicopters,{{Cite web |title=The Ambulance Team - Health New Zealand {{!}} Te Whatu Ora |url=https://www.tewhatuora.govt.nz/corporate-information/about-us/expert-groups/ambulance-team#aotearoa-new-zealands-emergency-ambulance-services |access-date=2025-02-02 |website=www.tewhatuora.govt.nz |language=en-NZ}} this could be reduce to just one in 2025.{{Cite web |date=2025-02-02 |title=Rescue helicopter contracts to change under redesign of aeromedical model |url=https://www.rnz.co.nz/news/national/540631/rescue-helicopter-contracts-to-change-under-redesign-of-aeromedical-model |access-date=2025-02-02 |website=RNZ |language=en-nz}} Each is owned by various location organisations that operate the helicopters. Covering the upper North Island is Northern Rescue Helicopter Ltd, owned by Northland Emergency Services Trust, and Auckland Rescue Helicopter Trust.{{Cite web |title=HOME |url=https://www.nrhl.co.nz/ |access-date=2025-02-02 |website=Northern Rescue |language=en}} The rest of North Island is covered by Central Air Ambulance Rescue Limited (CAARL), which is owned by five regional charitable Trusts.{{Cite web |title=Central Air Ambulance Rescue Limited |url=https://www.caarl.org.nz/ |access-date=2025-02-02 |website=Central Air Ambulance Rescue Limited |language=en-NZ}} Helicopter Emergency Medical Services Ltd (HEMS), covers the whole of South Island, it is owned by GCH aviation and HeliOtago.{{Cite web |url=https://hemsnz.com/about/ |title=Who we are |publisher=HEMS New Zealand Ltd.|access-date=2025-02-16 |website=hemsnz.com}} The New Zealand government funds $140m that covers most, but not all, of the air ambulance costs. The remaining costs are covered by fundraising from charitable trusts. Most of the trusts or individual helicopters are sponsored by a commercial entity and bear its name for marketing purposes; for example Auckland, Waikato, Wellington and Christchurch helicopters are sponsored by the Westpac Banking Corporation and branded as "Westpac Rescue" while others include the Taranaki Energy Rescue Helicopter, Eastland Helicopter Rescue Trust (EHRT), Bay Trust Rescue Helicopter, etc. Clinical crew (typically Intensive Care Paramedics) for the helicopters are full time employed Intensive Care Paramedics.

Domestic fixed wing air ambulance and patient transfers services, are provided by four organisations. Skyline Aviation, that is supports Starship Hospital. Life Flight Trust that is part of CAARL for its rescue helicopter service. GCH Aviation operates flying doctor service. Stewart Island Flights are also used for patient transfers. Typically use pressurised and converted Fairchild Metro aircraft, equipped as flying Intensive Care units.{{cite web|url=http://www.lifeflight.org.nz/home.php|title=LifeFlight home page|access-date=9 February 2009|archive-url=https://web.archive.org/web/20090204205408/http://www.lifeflight.org.nz/home.php|archive-date=4 February 2009|url-status=dead|df=dmy-all}} and it has been estimated that after corporate sponsorship and government subsidy, it is necessary to raise approximately NZ$2,500 (around US$1,400 in 2009) in donations for each mission.{{cite web|url=http://www.lifeflight.org.nz/how_you_can_help.php|title=How You Can Help (LifeFlight official website|access-date=9 February 2009|archive-url=https://web.archive.org/web/20081230145326/http://www.lifeflight.org.nz/how_you_can_help.php|archive-date=30 December 2008|url-status=dead|df=dmy-all}}

Fire and Emergency New Zealand (FENZ) provides a medical 'First Response' in smaller communities where there is no local ambulance service. These fire personnel are trained to a higher standard than regular firefighters and are equipped with basic ambulance equipment.

As of Christmas 2013, FENZ 'Co- Responds' to all "Code Purple" (typically cardiac or respiratory arrest) emergencies St John Ambulance and Wellington Free Ambulance attends nationwide.

The standard FENZ response to a medical emergency is one fire appliance equipped with an automated external defibrillator and oxygen therapy kit.

The New Zealand Defence Force has personnel and equipment available at short notice to assist in civilian matters including medical emergencies.{{cite web|url=http://www.nzdf.mil.nz/public-documents/soi/2007/part-a/section-3/services-in-support-of-the-govt.htm|title=Services in Support of the Government and the Community|publisher=New Zealand Defence Force|access-date=20 February 2009}}

The New Zealand system functions on the Anglo-American model of care,{{cite journal|vauthors=Cooke MW, Bridge P, Wilson S |title=Variation in emergency ambulance dispatch in Western Europe|journal=The Scandinavian Journal of Trauma and Emergency Medicine|volume=9|issue=2|pages=57–66|year=2001}} with most care in the pre-hospital setting being conducted by paramedics. Other practitioners, including local physicians and midwives, do appear at calls from time to time, but spend much less time responding to emergency calls than the Franco-German model.{{cite journal |author=Dick WF |title=Anglo-American vs. Franco-German emergency medical services system |journal=Prehosp Disaster Med |volume=18 |issue=1 |pages=29–35; discussion 35–7 |year=2003 |pmid=14694898 |doi= 10.1017/s1049023x00000650|s2cid=31020961 }}

The clinical education of Ambulance staff in New Zealand historically draws parallels to the Anglo-American development of the Paramedic profession generally but has undergone radical transformation in the past decade closely mirroring developments pursued by nations such as Australia, South Africa, Canada and the United Kingdom

Prior to 1977 the "training" of Ambulance Officers was arranged in an ad-hoc fashion to a varying degree of first aid preparation to enable passage of a national examination administered on behalf of the Department of Health by an Examination Board of the Order of St John; a requirement established by the Ambulance Transport Advisory Board in 1963. Despite the content of this examination being described as "very basic"

Dare, A. O. (1977). Ambulance Services in New Zealand. Retrieved from Ambulance Transport Advisory Board website: http://www.moh.govt.nz/notebook/nbbooks.nsf/0/FBED37F694813C494C2565D70018F243/$file/12232.pdf{{Dead link|date=May 2019 |bot=InternetArchiveBot |fix-attempted=yes }}

the requirement for some degree of formal Ambulance Officer education and training is one of the earliest in the world; in contrast the Ambulance Service of New South Wales established the Ambulance Education Centre at Rozelle (Sydney) in 1961 – although the first graduates were not until 1966,Ambulance Service of NSW (4 February 2011). AEC 50th Anniversary. Retrieved 15 June 2013, from http://www.ambulance.nsw.gov.au/Media-And-Publications/Latest-News/AEC-50th-Anniversary.html {{Webarchive|url=https://web.archive.org/web/20110720061258/http://www.ambulance.nsw.gov.au/Media-And-Publications/Latest-News/AEC-50th-Anniversary.html |date=20 July 2011 }} Geelong & Districts Ambulance in Victoria (Australia) began a training school in 1962 Monash University Department of Community Emergency Health and Paramedic Practice (n.d.). A Brief History of Ambulance Education in Victoria. Retrieved 15 June 2013, from {{cite web |url=http://www.med.monash.edu.au/cehpp/gen-info/history.html |title=A Brief History of Ambulance Education in Victoria |access-date=2013-06-16 |url-status=dead |archive-url=https://web.archive.org/web/20130428094742/http://www.med.monash.edu.au/cehpp/gen-info/history.html |archive-date=28 April 2013 |df=dmy-all }} and the province of Ontario (Canada) implemented a requirement for a five-week, 160-hour "Fundamentals of Casualty Care" course for ambulance attendants in 1967.Ontario Paramedic Association (n.d.). History of Paramedics and EMS « Ontario Paramedic Association. Retrieved 15 June 2013, from http://www.ontarioparamedic.ca/paramedics/our-history/

Into the 1970s there was considerable development of local training amongst ambulance services over-and-above the basic DOH/ATAB requirement; this training particularly focussed on defibrillation to treat cardiac arrest and was most notable in Christchurch, Wellington and Auckland; with Auckland introducing the first Mobile Intensive Care (Life Support Unit) on the North Shore in 1970 however other subjects covered included the administration of entonox (nitrous oxide) for pain relief and the taking of a patient's blood pressure.Rice, G. (1994). Ambulances and first aid: St. John in Christchurch, 1885–1987 : a history of the St. John Ambulance Association and Brigade in Christchurch, New Zealand. Christchurch [New Zealand]: Order of St. John. The introduction of out-of-hospital defibrillation by civilian Paramedics to New Zealand (1970) is again among the earliest examples in the world; predated only by the original 1966 Pantridge Experiment in Belfast (Northern Ireland) Geddes, J. (2007). Pioneers in Cardiology: Frank Pantridge, CBE, MC, MD, FRCP, FACC. Circulation, 2007(116), 145–148. Retrieved from http://circ.ahajournals.org/content/116/25/F145.full.pdf and its earliest direct replication projects by the Miami Fire Department ("Rescue 1" in March 1967 under Dr. Eugene Nagel) The Virtual EMS Museum (2 August 2011). 1967: City of Miami Fire Department Paramedic Program. Retrieved 16 June 2013, from http://www.emsmuseum.org/virtual-museum/history/articles/399754-1967-City-of-Miami-Fire-Department-Paramedic-Program {{Webarchive|url=https://archive.today/20130619222316/http://www.emsmuseum.org/virtual-museum/history/articles/399754-1967-City-of-Miami-Fire-Department-Paramedic-Program |date=19 June 2013 }} and New York City with the Mobile Coronary Care Unit established by Dr. William Grace of St. Vincents Hospital) also introduced in 1967.The Virtual EMS Museum (10 June 2008). 1968: William Grace, MD. Retrieved 16 June 2013, from http://www.emsmuseum.org/virtual-museum/history/articles/398198-1968-William-Grace-MD {{Webarchive|url=https://archive.today/20130619222329/http://www.emsmuseum.org/virtual-museum/history/articles/398198-1968-William-Grace-MD |date=19 June 2013 }}

The National Ambulance Officers Training School (NAOTS) was established in 1977 using funds raised from the earlier 1975 Telethon and was administered by the Auckland Centre Trust Board of the St John Ambulance Association to fulfill its requirement to the Government (through the Ambulance Transport Advisory Board) to establish a national system of training for Ambulance Officers. NAOTS formalised training into three distinct levels of "Ambulance Aid" with each was a Certificate issued jointly by the Department of Health (through the ATAB) and the National Training School under the auspices of the Order of St John.Offenberger, W., & Walton, R. J. (1984). Review of New Zealand Ambulance Officer Training. Retrieved from Ministry of Health, Wellington website: http://www.moh.govt.nz/notebook/nbbooks.nsf/0/53D05EA7BCFA934A4C2565D7000E2DFD/$file/img-607125013-0001.pdf {{Webarchive|url=https://web.archive.org/web/20160304111847/http://www.moh.govt.nz/notebook/nbbooks.nsf/0/53D05EA7BCFA934A4C2565D7000E2DFD/$file/img-607125013-0001.pdf |date=4 March 2016 }}Hunt, G. J. (2010). First to Care: 125 years of the order of St John in New Zealand 1885 – 2010. Auckland, New Zealand: Libro International.

• Basic grade certification as either six weeks full-time for paid officers or taught in two three-week blocks for volunteers over two years (three weeks each year) provided they had completed at least 400 hours of service in the year prior to commencing and in the year between blocks.
• Intermediate Aid consisted of six pre-course correspondence assignments, a two-week block course and two weeks of in-hospital experience. The initial provisions of the Intermediate Aid course were nebulised salbutamol, MAST and intravenous fluid administration.
• Advanced Aid built upon Intermediate Aid and required a minimum of three years' service. The fourteen-week course was spread over a five-week block course, four weeks each of in-hospital and on-road and then a one-week examining period. Once qualified in Advanced Aid (as a "Paramedic") an Officer could perform defibrillation, intubation, chest decompression and administer a number of drugs.

Walton and Offenberger compiled a review of the NAOTS (and Ambulance Officer training generally) for the Department of Health in 1984 which led to the following reforms:

• The School became affiliated with the (then) Auckland Institute of Technology (now AUT) and relocating out of the old Central Ambulance Station in Pitt St to the Akoranga Campus in 1990.
• Elementary Ambulance Aid was introduced to provide a national first step for volunteers
• The "Basic Grade Certificate in Ambulance Aid" was renamed "Proficiency Ambulance Aid"
• Intermediate Aid was changed to form two "Post-Proficiency Modules" one in Monitoring/Defibrillation and the other Intravenous Therapy.
• Medical treatment protocols for Intermediate and Advanced Aid became the responsibility of the Ambulance Transport Advisory Board (later the New Zealand Ambulance Board) as they had initially been developed by the NAOTS however this was seen to be unsatisfactory as it was deemed a responsibility of the medical profession whereas NAOTS was an educational body.

The review also consideration the necessity of using qualified Ambulance Officers when undertaking non-emergency transfer duties; this can be seen today as the Patient Transport Service whereby transfers of nonemergency patients between hospitals, clinics and home are provided by staff who have only minimal clinical training (First Responder) as this is the need dictated by their duties. It was recommended that the Ambulance qualifications offered through NAOTS be recognised by the Authority for Advanced Vocational Awards (AAVA).

With the Bolger led National Government reforms of the 1990s; the New Zealand Qualifications Authority was established to replace the AAVA New Zealand Qualifications Authority (August 2000). QA News August 2000 – NZQA. Retrieved 15 June 2013, from https://web.archive.org/web/20071222094712/http://www.nzqa.govt.nz/publications/newsletters/qanews/october-2000/file-7.html and by 1996 the NAOTS certifications were shifted onto the newly established Nationals Qualifications Framework thus became formal vocational qualifications of higher learning. Proficiency Ambulance Aid was replaced by the National Certificate in Ambulance (Patient Care and Transport) New Zealand Qualifications Authority (2008). National Certificate in Ambulance (Patient Care and Transport). Retrieved 15 June 2013, from http://www.nzqa.govt.nz/nqfdocs/quals/pdf/0206.pdf while the National Diploma in Ambulance (Paramedic) replaced both Post-Proficiency Modules (Intermediate Aid) as well as Advanced Aid however in practice the Intermediate Aid qualification was still offered as two Unit Standards from the Diploma.New Zealand Qualifications Authority (November 2009). National Diploma in Ambulance (Paramedic). Retrieved 15 June 2013, from http://www.nzqa.govt.nz/nqfdocs/quals/pdf/0207.pdf

The National Training School closed in 1999 as it had "become dysfunctional" St John New Zealand (2007). Appendix 1: St John submission to Health Committee NZ House of Representatives. and the recently introduced Ambulance Education Council considered that a drive towards regional service-led training was best Costa-Scorse, B. (2008) "Submission on the Inquiry into the provision of Ambulance Services in New Zealand, Journal of Emergency Primary Health Care: Vol. 6: Iss. 3, Article 2

thus began a decade of inconsistency within clinical education, although not as great as to return to the pre-NAOTS era of splintification.

Following closure of the National Training School and disbanding of the New Zealand Ambulance Board which had previously published the National Authorised Patient Care Procedures each service took on responsibility for its own clinical education and standing orders (patient care procedures) which would further aggravate regional differences and ultimately, help lead a return to nationalised clinical education.

In 1999 a programme of "Intermediate Care Upskilling" was introduced by St John (initially in the Auckland District Federation of Ambulance Officer Unions of New Zealand (2007). Ambulance – An Emergency Service in Crisis.) to equip selected ICOs with adrenaline, morphine, naloxone and (at the time) metoclopramide. This distinct training package was not part of any formal qualification.Werner, S. A. (2011). Pain assessment and pain alleviation practices of ambulance officers in Auckland: A thesis submitted to Auckland University of Technology in partial fulfilment of the requirements for the degree of Master of Health Science (MHSc). Retrieved from School of Health Care Practice; Auckland University of Technology website: http://aut.researchgateway.ac.nz/bitstream/handle/10292/1401/WernerS.pdf?sequence=3 {{Webarchive|url=https://web.archive.org/web/20140423053839/http://aut.researchgateway.ac.nz/bitstream/handle/10292/1401/WernerS.pdf?sequence=3 |date=23 April 2014 }} St John also merged the two Post-Proficiency modules back into one education programme at some point during this time so that an officer became qualified in both portions of Intermediate Aid concurrently. Wellington Free Ambulance chose to adhere to the original Post-Proficiency module design thus retaining two distinct practice levels (cardiac and IV/cardiac). They also developed their own upskilling programme known as "advanced life support" consisting of two modules, A and B; module A contained cardiac arrest drugs (at the time adrenaline, atropine and lignocaine) while Module B provided intravenous pain relief along with naloxone and metoclopramide.Wellington Free Ambulance (2005). Wellington Free Ambulance – Ambulance Services-Home. Retrieved 15 June 2013, from https://web.archive.org/web/20051229204730/http://www.wfa.org.nz/ambulance-services/default.asp

To coincide with introduction of the various upskilling packages in the early 2000s there was a move away from the once nationally consistent qualification titles (Ambulance Officer, Intermediate Care Officer, Advanced Care Officer (Paramedic)) that existed under the National Training School to the introduction of new titles into each of the services. St John renamed Intermediate Care Officer to "Paramedic" and Paramedic (ACO) to "Advanced Paramedic" in 2001 along with a new national uniform.St John New Zealand (2002). Yearbook 2002. Retrieved 15 June 2013, from [https://web.archive.org/web/20081015065138/http://www.stjohn.co.nz/files/200356_20041027845.PDF] Wellington Free Ambulance chose to rename all staff qualified at National Certificate (Proficiency) or Intermediate Aid to "Paramedic" and their Paramedics (ACOs) to "Intensive Care Paramedic".Brown, L., Eckhoff, M., Lindley, G., & Jones, S. (2002). A handbook for new and locum rural nurses. Centre for Rural Health, Ministry of Health, Wellington. Retrieved 15 June 2013, from http://www.health.govt.nz/system/files/documents/pages/handbook_new_locumruralnurses.pdf There is anecdotal suggestion that the renaming of staff who did not hold the full National Diploma/Advanced Aid to "Paramedic" was due in part to the high media profile of programs such as Third Watch and Rescue 911 which glorified and glamorised the role of "Paramedic" thus giving the public an expectation that they, as on TV, should be attended to by a "Paramedic". It has also been recorded that the move to rename Intermediate Care Officer to "Paramedic" on the part of St John was somewhat motivated by their desire to expedite contract negotiations with the Ministry of Health and ACC which required a certain number of "Paramedics" however it can be logically assumed that the contract did not actually define what a "Paramedic" was, as the original definition of a Paramedic in New Zealand was somebody qualified to National Diploma/Advanced Care level.

With the demise of NAOTS; Auckland Institute of Technology, having been awarded University status and renamed Auckland University of Technology, developed the Bachelor of Health Science (Paramedic) degree while Victoria University (Melbourne) partnered with Wellington Free Ambulance to create a tertiary Paramedic degree administered through Whitireia Community Polytechnic. In 2003 St John began to require completion of the Bachelor of Health Science (Paramedic) for those staff who wished to move to the Advanced Life Support (Advanced Aid) qualification level. Wellington Free introduced an "Intern Paramedic" position in 2004 to accommodate staff who would completing the Degree while also working on the road at the same time.

By the late 2000s there was a need to once again bring reform to clinical education; and although not as marked as those introduced during the time of the National Training School the following issues needed urgent attention St John New Zealand (2006). Yearbook 2006. Retrieved 15 June 2013, from [https://web.archive.org/web/20081015061843/http://www.stjohn.co.nz/files/200935_20061121223.PDF]

• Introduction of tertiary degrees and the apparent double standard this created compared to more technically focussed vocational qualifications centred around a narrow scope of knowledge; coupled to this the ongoing viability of NZQA Unit Standards as a realistic platform to deliver comprehensive paramedic education (many felt they had outlived their useful life for higher practice levels)
• Moves by comparative jurisdictions in Australia totally towards tertiary education only
• The lack of a distinct qualification for the intermediate tier practitioner; originally the Certificate in Intermediate Aid was awarded upon completion of the ICO course however with the introduction of the National Certificate and Diploma in 1995 there was no longer a distinct external qualification for this level and this was even more true for the "upskilled" provider as this was an internally run course
• The need for structured ongoing clinical education once a qualification had been gained
• The very low completion rate of the National Certificate by volunteers (19%) when considering the goal of NAOTS had been to qualify all Ambulance Officers to the "basic" level (originally Proficiency but later National Certificate)
• Increasing complexity of ambulance practice beyond "scoop and run" and early Paramedic practice focussing mainly on early defibrillation/cardiac arrest and trauma care
• Increasing chronic disease,
• Impracticality of delivering all patients to a hospital emergency department, particularly in the face of increasing chronic disease or mental health problems which are not ideally handled in an acute presentation to ED.
• Increasing public expectation (see above)
• Inconsistency between service providers' levels of practice and the requirements of a newly introduced Ambulance Sector Standard which defined three levels of practice (discussed below)
• The long-held view (since 1993) that Paramedics should be registered health practitioners in their own right.Department of Health (1993). Report of the Consensus Conference on Emergency Ambulance Services; April 1993. Retrieved from http://www.moh.govt.nz/notebook/nbbooks.nsf/0/93CD3A89E7A60C9A4C2565D70018F279/$file/92209.pdf {{Webarchive|url=https://web.archive.org/web/20160304113715/http://www.moh.govt.nz/notebook/nbbooks.nsf/0/93CD3A89E7A60C9A4C2565D70018F279/$file/92209.pdf |date=4 March 2016 }}

The 2007 Health Select Committee report into the provision of ambulance services and the resulting National Ambulance Service Strategy included requirements to "achieve national consistency" in ambulance education and scope of practice (clinical competency). St John had during this time developed a draft "Operations Competency Framework" which would become the foundation of more recent developments;St John New Zealand (2008). Annual Report 2008. Retrieved 15 June 2013, from {{cite web |url=http://www.stjohn.org.nz/Global/Documents/Publications/Annual%20Report/annual_report_2008.pdf |title=Archived copy |access-date=2013-06-16 |url-status=dead |archive-url=https://web.archive.org/web/20130209055929/http://stjohn.org.nz/Global/Documents/Publications/Annual%20Report/annual_report_2008.pdf |archive-date=9 February 2013 |df=dmy-all }} specifically the replacement of the National Certificate, the requirement for all the various intermediate level officers to transition to a new "Paramedic" level which would approximate the "Upskilled Paramedic (ALS-A/ALS-B)" levels and become a Degree course, the development

In 2008 the National Diploma in Ambulance Practice (Level 5) replaced the National Certificate in Ambulance Patient Care and Transport (Level 4) as the qualification for the basic life support level.New Zealand Qualifications Authority (2010). National Diploma in Ambulance Practice. Retrieved 15 June 2013, from http://www.nzqa.govt.nz/nqfdocs/quals/pdf/1408.pdf

The National Diploma is required to be referred to as an EMT (Emergency Medical Technician).

The Diploma is a "blended" learning programme comprising approximately 1,300 hours of online and in-class learning plus on-road clinical experiences.ETITO (2010). ETITO Annual Report 2010. Retrieved 15 June 2013, from http://skills.org.nz/assets/ETITO%20Annual%20Report%202010.pdf {{Webarchive|url=https://web.archive.org/web/20130209105735/http://skills.org.nz/assets/ETITO%20Annual%20Report%202010.pdf |date=9 February 2013 }} There are three modules (core skills, medical and trauma) which each have an online component prior to classroom education and this theoretical component is run concurrently while a student is practicing in the operation environment thus building the requisite base of experience to become a qualified Ambulance Officer.St John New Zealand (2010). Clinical Education Prospectus (November 2010).

• Core Skills (four weeks online and 2 days in-class) covering scene assessment, primary/secondary survey and vital signs, resuscitation, defibrillation
• Trauma (six weeks online and 6 days in-class) covering trauma and anatomy, shock and anaphylaxis, chest injuries, soft tissue injuries, environmental, head and spine
• Medical (six weeks online and 6 days in-class) covering cardiac and respiratory, children's health, pregnancy, childbirth and newborns, older persons health, abdominal, diabetes, stroke, seizures, altered levels of consciousness, scene management, mental health

While the format of the qualification has changed significantly in the move to predominantly online learning that the actual content of has not been reduced; if anything it has increased considering the National Certificate had twenty-eight credits at level 5 whereas the Diploma has one hundred and eleven. The number (and focus) of classroom days have been changed due to the majority of theoretical learning taking place online and classroom days heavily focussing on the psychomotor aspects of ambulance practice rather than teaching and assessing anatomy, physiology and pathology in great detail.

During (and after) the online and class phases of National Diploma the student must complete a Portfolio of Evidence for presentation at the End of Course Interview and Assessment. The Portfolio requires the student to demonstrate integrated clinical practice as well as self-reflection/professional development through skill logs, mentor reports and exemplars.

A Bachelor's degree in Paramedicine (Level 7) is set to be required nationally for the intermediate life support level as of 2014.St John New Zealand (2008). Our Road to Clinical Excellence: Introducing our new clinical framework and how we will make it happen. While it has essentially become the de facto standard for entry to the profession St John still offer an internal ILS course for currently practicing paid staff who wish to move to the ILS level from either the old Paramedic level (intermediate aid) or the BLS level (Certificate or Diploma). The Degree was scheduled for introduction by the beginning of 2012 St John New Zealand (2010). Our Road to Clinical Excellence: Update on Progress(May 2010). however it is understood that there have been delays in assembling a realistic framework to transition totally away from an in-service education model.

The degree is required to be referred to as a Paramedic.

The degree is a comprehensive education programme over three years consisting of 3,600 hours of learning which enables students to build a solid foundation of knowledge, skill, rationale and clinical judgement to the ILS level as a mixture of classroom, simulation suite and practical (on-road) experience catering for both school leavers who wish to pursue a Paramedic career (in the same way at other health professional degrees) and also for working Ambulance Officers who wish to upgrade their knowledge and obtain a tertiary qualification.

There were previously suggestions by St John that the organisation may follow Western Australia, the Northern Territory and the Ambulance Service of New South Wales by offering employment at a defined exit point of the Degree allowing the student to essentially become a BLS Emergency Medical Technician full-time and complete the rest of the degree over a number of years and qualify as an ILS Paramedic. This pathway appears to no longer be being considered.

A Postgraduate Certificate (Level 8) is, as of 2013, the required qualification to reach ALS level (known as Intensive Care Paramedic) and is offered by AUT as the Postgraduate Certificate in Emergency Management or Whitireia as the Postgraduate Certificate in Specialty Care (Advanced Paramedic Practice).

The Postgraduate Certificate is required to be referred to as an ICP (Intensive Care Paramedic).

The focus of this qualification is to build upon the Paramedics' knowledge and skillset to deliver advanced resuscitation interventions such as intubation, rapid sequence induction, chest decompression, thrombolysis and pacing as well as developing more advanced capability in clinical leadership and decision-making.

The revised New Zealand Ambulance and Paramedical Service Standard (NZS8156:2008) defines three levels of practice and gives guidance as to their depth and breadth Standards New Zealand (2008). Ambulance and paramedical services (NZS8156:2008). but it does not however define the specific interventions to be included in each (scope of practice). The specific scopes of practice are set every two years as part of the Clinical Practice Guidelines developed by the Clinical Working Group (part of Ambulance New Zealand) which consists of the medical directors, medical advisors and paramedic representatives from both St John and Wellington Free Ambulance as well as the New Zealand Defence Force.

Although the standard is more or less correct, there are aspects of practice which have evolved since it was written. ECG interpretation is a good example, where in-depth 12 lead ECG interpretation is now taught at ILS level as part of the degree where at the time of writing the Standard (2008) this level of skill was generally reserved for ALS practitioners given the number of practicing graduates was smaller at that time.

Like other similar systems around the world such as South Africa, the UK and Australia, and in sharp polar contrast to the United States and (to a lesser degree) Canada, the system of practice is entirely based upon the professional discretion of the attending ambulance officers, and there is no need for "online medical direction" to obtain approval for drugs or procedures. There is however a strong system of collegial support via the communications centre Clinical Desk (and on-call Medical Advisors) to assist with clinical decision-making when required, this however is not a system of seeking permission.New Zealand Government (2012, August 0). Better clinical advice for 111 calls. Retrieved 15 June 2013 from http://www.beehive.govt.nz/release/better-clinical-advice-111-calls

The below Delegated Scopes of Practice are as per the 2013–2015 Clinical Procedures and Guidelines

Basic pre-hospital emergency care (PHEC) medication can be used by staff in the entry level of ambulance care (event staff and new volunteers).

Current scope of practice: Paracetamol, ibuprofen, aspirin, oxygen therapy, intermittent positive pressure ventilation (IPPV), oropharyngeal airway (OPA), nasopharyngeal airway (NPA). Additionally, certain medications from the EMT scope of practice may be given by a First Responder with Clinical Direction from an EMT/Paramedic/ICP at the scene or via the St John/WFA Clinical Desk.

General pre-hospital emergency care to assess and manage both life-threatening and non-life-threatening situations using knowledge, skills and clinical judgement appropriate to generally non-invasive techniques and non-intravenous drug regimens.

Current scope of practice: 3/12 lead ECG acquisition, nasopharyngeal airway, nebulised salbutamol, nebulised ipratropium, GTN (SL and Transdermal), IM glucagon, laryngeal mask airway, ondansetron (intramuscular), loratadine, Ibuprofen, Methoxyflurane, PEEP valve, adrenaline (IM, IN and nebulised), Prednisone, Prednisolone, Tramadol, urinary catheter troubleshooting, laryngoscopy, Magill forceps.

Knowledge and skill to provide invasive care that significantly builds upon BLS capacity in terms of clinical judgement and capability including a wide range of pharmacology.

Current scope of practice: All of the above plus manual defibrillation, synchronised cardioversion, IV cannulation, IV fluid administration, IV glucose, morphine, fentanyl, naloxone, ondansetron, adrenaline (IV) for cardiac arrest, amiodarone (IV) for cardiac arrest, ceftriaxone, midazolam (IM) for seizures, oxytocin, clopidogrel, lignocaine (SC) for ring blocks.

Provides advanced management where knowledge, rationale, judgement, skill and leadership are well developed and utilises the most comprehensive regime of pharmacology, airway support and ECG interpretation.

Current scope of practice: All of the above plus laryngoscopy, endotracheal intubation, capnography,

cricothyrotomy, chest decompression, IO access, IO lignocaine, adrenaline, atropine, amiodarone, adenosine, calcium chloride, sodium bicarbonate, midazolam, ketamine, pacing, rocuronium, rapid sequence induction (select personnel only)

Additionally, there is a "First Responder" level used for non Ambulance work (such as Events and non emergency transfers (PTS)) as well as community first response in rural areas, as an initial starting point for those on the clinical education pathway (i.e. completing the Diploma or above) or where the standard education pathway has been found unsuitable for a volunteer. This level does not have an "authority to practice" and does not independently utilise the Clinical Practice Guidelines or many pieces of clinical equipment.St John New Zealand (2010). First Responder Explained

The Trustees of Ambulance New Zealand submitted an application to the Minister of Health in June 2011 that requested Paramedic and Intensive Care Paramedic be included as registered health professions and this is expected to be approved later in 2013.Paramedics Australasia (2012). Paramedic Registration in New Zealand. Retrieved 15 June 2013 from {{cite web |url=https://www.paramedics.org.au/news/nz/paramedic-registration-in-new-zealand/ |title=Paramedic Registration in New Zealand : Paramedics Australasia |access-date=2013-06-16 |url-status=dead |archive-url=https://web.archive.org/web/20130429021726/https://www.paramedics.org.au/news/nz/paramedic-registration-in-new-zealand/ |archive-date=29 April 2013 |df=dmy-all }} Registration would mean that a responsible authority (RA) under the Health Practitioners Competency Assurance Act would become responsible for governing Paramedic practice in New Zealand that practitioners would ultimately be responsible to this professional body which would be a significant change from the current "employer led" regulation.

The EMS system in New Zealand is served by three dispatch centres, located in Auckland, Wellington, and Christchurch. The dispatch centre in Christchurch provides coverage to the entire South Island, and is operated by St. John Ambulance. The dispatch centre in Auckland provides coverage for the north half of North Island, and is also operated by St. John Ambulance. The dispatch centre in Wellington provides coverage for the southern half of the North Island, is jointly operated by Wellington Free Ambulance and St John Ambulance but is staffed by Wellington Free Ambulance personnel. All three dispatch centres collaborate, and are capable of handling overflow of call volume for one another.{{cite web|url=http://www.wfa.org.nz/Comms.htm|title=Comms Centre (WFA website)|access-date=11 February 2009|archive-url=https://web.archive.org/web/20081014072828/http://www.wfa.org.nz/Comms.htm|archive-date=14 October 2008|url-status=dead}} The communication centre technology is fully integrated and seamless, providing a single, 'virtual' national dispatch centre. To illustrate, if an emergency has occurred in Christchurch but those 111 lines are all busy, the call will be forwarded to the dispatch centres in either Auckland or Wellington. The call will be answered, information gathered, and placed into the computer network. It will then appear as a pending call on the desk of the appropriate dispatcher in Christchurch, all seamlessly.

The national emergency number for ambulances in New Zealand is 111.

The three dispatch centres also include significant advanced technologies, including AMPDS and Siren software for the triaging and assignment of calls. They also include a nationwide network of Automatic Vehicle Location (AVL), showing the location and current status of every ambulance in the country.{{cite web|url=http://www.111.govt.nz/technology/latest_technology_ambulance.html|title=Comms Centre Technology (NZ govt 111 website)|access-date=11 February 2009|archive-date=14 October 2008|archive-url=https://web.archive.org/web/20081014042012/http://www.111.govt.nz/technology/latest_technology_ambulance.html|url-status=dead}} All dispatchers in New Zealand are certified Emergency Medical Dispatchers (EMDs), and meet the international standard for that qualification. Between them, the ambulance dispatch centres process approximately 300,000 calls per year originating with the 111 system. They also process an additional 800,000 calls per year from GPs, hospitals requesting transfers, medical alarm monitoring companies, and from paramedics themselves.{{cite web|url=http://www.111.govt.nz/technology/no_of_calls.html|title=No. of Calls per year (New Zealand government 111 website)|access-date=11 February 2009}}

The telephone triage system used within the communication centres is the internationally regarded Advanced Priority Medical Dispatch System also known as ProQA whereby the caller is interrogated to determine the most appropriate problem detriment to guide the level of response in terms of speed and clinical capability.

Paramedics Australasia is the peak professional body representing paramedics throughout New Zealand and Australia [http://www.paramedics.org www.paramedics.org]. Established in New Zealand in October 2011, Paramedics Australasia provides representation on professional paramedic issues, advocacy before government, and responds to media comment on professional paramedic issues.

Paramedics Australasia sponsors the annual New Zealand national paramedic conference (SPANZ - in conjunction with Student Paramedics Australasia) which alternates between AUT University in Auckland and Whitireia Polytechnic in Wellington.

• Wellington Free Ambulance
• St. John Ambulance in New Zealand

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• [https://web.archive.org/web/20101130085538/http://www.wairarapa.dhb.org.nz/WDHB/HealthServices/Ambulance.aspx]

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