NIST's design had twin work stations with seats that rotated toward the patient and storage in back.
Photo credit: NIST
A Sprinter ambulance used by Oslo University Hospital.
Photo credit: Oslo University Hospital
Welcome to the third installment of EMS 2020. Last month we examined risk in EMS. This month’s content looks at efforts to develop standards that can improve the safety of the ambulance environment.
POLICY: Exempt from key safety requirements and often poorly laid out, ambulances are relatively unsafe places to work and travel.
STRATEGY: Federal bodies, private entities and others are working to develop better standards for ambulances and their components in hopes of improving outcomes in crashes.
VISION: Ambulances that are more safely constructed, more efficiently laid out, and encompass proven safety measures will better protect providers.
The ambulance environment may not be optimally safe or ergonomic, but there are a lot of people working to make it better.1 Those who operate individual ambulances or entire fleets should understand what’s at stake, who’s playing and the parameters of current efforts. Here’s an update.
The U.S. Government
Spurred by the high rate of EMS worker injuries, the National Institute for Occupational Safety and Health (NIOSH) has been working for nearly a decade with a variety of industry partners, including the National Truck Equipment Association’s Ambulance Manufacturer’s Division (AMD), on issues such as patient compartment restraints, and cot and equipment mounts. When the Department of Homeland Security, at the behest of its First Responders Working Group, ventured more recently into the realm of ambulances, it partnered with NIOSH, NIST (the National Institute of Standards and Technology) and other players in a comprehensive effort to redesign the compartment and strengthen key crash safety elements.
NIOSH’s work initially examined mobile restraints, but “a better design, certainly, would be to marry crashworthy seating, cots, interior equipment mounts and surfaces with a redesigned layout,” says Jim Green, who’s led the project for NIOSH’s Division of Safety Research. Conceiving a new layout is the charge of NIST and its partners.
“If we are fully successful and are able to provide a layout that allows the worker to complete all patient care tasks seated and restrained,” Green says, “we would, in effect, eliminate the need for restraints that allow full mobility.”
NIST’s arm of the project began in 2011; it spent nearly a year gathering input from EMS stakeholders on what worked, didn’t and needed to change. Three major points emerged: Providers had to be able to reach patients from head to knee; reach critical equipment and supplies; and maintain face-to-face interaction with the patient, all while seated and restrained.
“I think all providers want to be seated and restrained, but there are things they feel they can’t do from that position, such as CPR and intubation,” says Jennifer Marshall of NIST’s Law Enforcement Standards Office, the project’s manager. “We’ve been working to find a solution to that, but it’s a challenging area.”
An initial conceptualization displayed at last year’s EMS World Expo featured twin attendant work stations on either side of the cot, with seats that swiveled 90 degrees to reach the patient and a sliding airway seat at the head. That’s since been refined, and work is ongoing; a newer version is coming this month, and comments are still welcome.
What NIST, NIOSH and their partners come up with should work its way into the first revision of the NFPA 1917 standard for automotive ambulances, scheduled for 2015. A guidebook of best practices collected from the NIST research will precede it in 2014.
NFPA 1917 functionally replaces the familiar GSA Triple-K purchasing spec. It incorporates elements of that and the Ambulance Manufacturers Division’s manufacturing standards, which describe tests for various components. It is not a safety standard (ambulances are largely exempt from the Federal Motor Vehicle Safety Standards), but a design standard intended to provide a single threshold to which ambulances can be commonly built.
A fair amount of debate has accompanied 1917. Some industry leaders have questioned the cost and feasibility of building to it, and the National Association of State EMS Officials lodged a pair of requests for tentative interim amendments (TIAs) to modify it, including one for deletion of a controversial 77-mph speed limiter. That change is expected to be approved this month.
NASEMSO is forming a work group to offer comment during the 1917 revision process and has launched its own Model Rules for Ambulance Vehicle Design project to develop model ambulance-design regulatory language for states (see sidebar). It also successfully lobbied the GSA to delay retirement of the Triple-K from 2013 until 2015.
Charleston County (SC) EMS director Don Lundy articulated some specific concerns at last year’s EMS World Expo, including attachment of restraints and stretcher mounts to wood instead of metal and retention of the side-facing squad bench, a danger in frontal collisions. More generally, the EMS Safety Foundation has urged greater collaboration with automotive and technical experts and that occupant injury and fatality data better inform the standards-setting process.
None of this is to say NFPA 1917 is without merit. It’s a significant step forward from the Triple-K, and the industry can utilize the NFPA’s regular revision process to change, supplement and strengthen any weaker parts of the document as it matures.
“We tried to create a baseline that brought together the best practices in the community today,” says Green, a member of the 1917 technical committee. “The NFPA is very aware of what’s going on at DHS, NIOSH, NIST and within the ambulance manufacturing community. So it has already placed the standard back in the revision cycle, trying to pick up that research to improve the standard. There are also mechanisms in place to discuss and potentially change individual elements. There are a couple of changes to the existing standard already in place. But on the whole I think it’s a good standard and good starting point for the community.”
• A third standard in play is ASTM’s F2020-02a, which defines standard practices for designing, building and procuring EMS ambulances. It is produced by a technical committee on emergency medical services and reflects many aspects of the Triple-K.
• AMD’s manufacturing standards 001–025 are fully incorporated into the Triple-K specs, and partially into NFPA 1917 and ASTM F2020. They include static tests of such things as ambulance body structure, and litter and O2 tank retention.
• ANSI/ASSE Z15.1 is a standard from the American Society of Safety Engineers aimed at safer fleet operations. Among its requirements are written policies and accountability mechanisms, a driver selection/assessment program, training and reporting of incidents, trends and safety performance.
• The BSI Group’s ISO 39001 spells out requirements for road traffic safety management systems.
• The Society of Automotive Engineers provides recommended practices for testing restraint and equipment mounts in frontal (SAE J2917) and side-impact (SAE J2956) collisions.
• The EMS Safety Subcommittee within the Transportation Research Board’s Transportation Safety Management Committee held its most recent meeting in January. The subcommittee, ANB 10(5), promotes information exchange between disciplines and integration of interdisciplinary expertise into ambulance construction and design. Its work is extensively chronicled at www.objectivesafety.net.
Ambulance Specs and Standards Compared
As part of its Model Rules for Ambulance Vehicle Design (MRAVD) project, the National Association of State EMS Officials has compiled a handy comparison of U.S. ambulance guidance that contrasts NFPA 1917, the Triple-K standard and the ASTM’s F2020-02a, which defines standard practices for designing, building and procuring EMS ambulances. (ASTM was formerly the American Society for Testing and Materials.)
Find the chart at www.nasemso.org/Projects/AgencyAndVehicleLicensure/AmbulanceVehicleDesignProject.asp.
NASEMSO’s MRAVD project aims to produce model language states can use to govern ambulance design and identify options state vehicle specifications might include. Leaders hope the result will increase safety and cost-effectiveness, while reducing variation between states.
The project was spawned by the coming demise of the K specs (now postponed to 2015), which were created for federal purchasing but are utilized by many states to define what can be used as ambulances. Its replacement, NFPA 1917, “includes several departures from and additions to the KKK specs that have raised concerns among NASEMSO members,” the organization says.
The CEN 1789 Standard for European Ambulances
In the early years of the European Union, its leaders wanted to bring greater uniformity to their nations’ ambulance fleets. The standard they developed, CEN 1789, has now become regulation for the EU’s members.
First published in 2000 and revised most recently in 2007, CEN 1789 sets forth requirements for the design, testing, performance and equipping of EU ground ambulances. Its primary goal is safety, but also that ambulances be like enough to be recognized across countries and that personnel can easily work in any of them.
The standard covers both vehicle and engine types, as well as characteristics like size, acceleration and braking power, traction control, heating and cooling, and fire safety. Inside there are ergonomic requirements and specs for patient compartment design. Patient lifting is restricted, and safety measures are featured throughout. European ambulances are typically smaller, and equipment is arranged for seated and restrained reach by attendants. The CEN standard also specifies independent third-party testing by labs certified for the specific tests they perform. Manufacturers can’t do their own testing.
Other interesting aspects:
• Ambulances are classified as A1 or A2 (for nonemergency transports), B (for emergency use, with more treatment space and equipment storage), or C (mobile intensive care unit), with requirements increasing accordingly.
• Yellow—visible to almost all people in almost all conditions—is the primary color for all ambulances, with reflective green Battenburg markings running the length.
We’re still without key crashworthiness and occupant protection requirements, and the standards we do have are stronger in some parts than others. Improving them is a long-term process. The good news is that safety is at the forefront of considerations like never before, and a lot of smart, motivated people—in the public and private spheres, and including manufacturers, consultants and others across the spectrum—are laboring toward the same end.
“The goal is to provide the worker in the back of the ambulance with the same level of safety they’d have in their own vehicle driving to and from work,” says Green. “They have a moving workplace, and we’re trying to bring it up to that same level of safety.”