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Patient Care

The State of Pediatric Transport


The challenges: vehicle, cot and restraint devices are designed for adults. There is no federal standard to test crash worthiness of restraints on cots and no national crash standard available specific to stretchers or ambulances that can be used by manufacturers of ambulance restraints or child passenger safety seats.

In 2009 the National Highway Traffic Safety Administration (NHTSA) convened an expert interdisciplinary panel that developed guidelines based upon current pilot testing, manufacturers recommendations and existing standards for cars. The result was “Working Group Best-Practice Recommendations for the Safe Transportation of Children in Emergency Ground Ambulances,” published in 2012, which strives to put forth industry guidelines for properly restraining children in EMS vehicles. The ultimate goals of the recommendations were to prevent forward motion/ejection, secure the torso, and protect the head, neck, and spine of all children transported in emergency ground ambulances.

Two years in and the EMS industry in the U.S. is only incrementally closer to developing true universal standards for pediatric ambulance restraints. But the Best-Practice Recommendations have kept the discussion near the forefront of the industry, says one of its authors, Katrina Altenhofen, EMS for Children program manager in Iowa. And that’s a monumental step forward for an industry where kids often come a distant second to adults.

The Problem

Altenhofen says the whole reason why the EMS for Children program started back in 1985 was because EMS was built for the adult world. “It was built upon the 1966 Accidental Death and Disability: The Neglected Disease of Modern Society white paper, which said, we’ve got people dying on our roadways, from motor vehicle crashes we need a system by which we can treat their injuries and transport them to a healthcare facility. So for years it was adult, adult, adult, and then all of a sudden we were faced with pediatric patients who were NOT just small adults. When you look at the percentage of the pediatric call vs. the adult or geriatric call, it’s a smaller percentage, so they have a tendency to be forgotten about.”

According to the NHTSA document, estimates “suggest that ground EMS responds to approximately 30 million emergency calls each year. Approximately 6.2 million patient transport ambulance trips occur annually, of which approximately 10 percent of those patients are children. Insurance companies report that approximately 10,000 ambulance crashes result in injury or death each year. Estimates suggest that up to 1,000 ambulance crashes involve pediatric patients each year.”1

The problem isn’t so much that ambulances are crashing with kids in the back; it’s that in the U.S., unlike the U.K. and other countries, there aren’t any real standards for restraining patients-children or adults in the back of a moving ambulance.

“We knew going in to the whole process of writing the recommendations that all of us wanted to shoot for the moon,” Altenhofen says. “Many of us had a hard time actually trying to describe the problem in a 10 second sound bite because there are so many moving parts to this issue. Early into the process we had to be reminded to modify, or narrow, our scope realizing there would be limitations to the recommendations.”

That meant not looking at things like neonatal or inter-facility transport, and acknowledging the restraint devices the working group did consider don’t have crash test standards. “Our hope was maybe this document could keep pushing people toward that and we would keep this issue on the minds of our federal partners. And I can say that, yes, that has happened; for some of us, that has not happened as fast as we’d like to see it, but it is happening,” Altenhofen explains.

The Research

According to Altenhofen, when the working group began putting together its best practice recommendations it tried looking at existing research and hit a wall. “We did a literature search, and found there is no single national EMS dataset in the United States that can be analyzed to better understand the annual number of ambulance trips, the number that involve children, the frequency of ambulance crashes, the victims or types of injuries associated with such crashes, or the possible causes of such crashes. Now, since this document, it’s kind of brought forth more of an examination of best practices, or promising practices as I like to call them.”

Much of the research on pediatric ambulance restraint that does exist comes from two sources, Marilyn Bull, MD, an Indianapolis-based pediatrician specializing in neurodevelopment disabilities, and another of the NHTSA document’s authors, and Nadine Levick, MD, MPH, chair and CEO of Objective Safety, which provides expert insight on emergency transport safety and injury prevention. Both note deficiencies in current pediatric transport practices.

A report headed by Bull, “Crash Protection for Children in Ambulances,”2 sought to determine the most effective and reliable means of restraining children on an ambulance cot and to develop recommended field procedures for EMS providers.

In testing “successful” methods of securing a convertible child restraint and a modified car bed to the stretcher, it was determined the anchors for the cot did not fare well in dynamic testing. Additionally, usage of restraint devices designed for passenger vehicles were not recommended for emergency use by the manufacturer.

Further research by Bull notes utilizing a reinforced securing mechanism on the ambulance cot improves outcomes by 95%, but the cot head needs to be completely elevated to an upright seat position for optimal restraint.

Levick, a recipient of NHTSA funding to crash test ambulances, as well as funding from the Emergency Medical Services for Children (EMSC) National Resource Center to observe pediatric transport, found that of 200 ambulances observed carrying 206 pediatric patients more than half of the patients were laying of the stretcher, and 11% were unrestrained. Additionally, 27% of observed pediatric patients were unrestrained on the bench seat, 10% were on the lap of a parent or EMS provider and 13 different types of medical equipment were minimally secured or not secured at all.3

The Recommendations

While the best practice recommendations, available at, laid out in the NHTSA document aren’t a rigid standard, they do offer a variety of options EMS agencies can consider based on very specific situations (Table 1).1

Table 1: Situations Requiring Restraint of Pediatric Patients in Transport

Situation 1

For a child who is uninjured/not ill

Situation 2

For a child who is ill and/or injured and whose condition does not require continuous and/or intensive medical monitoring and/or interventions

Situation 3

For a child whose condition requires continuous and/or intensive medical monitoring and/or interventions

Situation 4

For a child whose condition requires spinal immobilization and/or lying flat

Situation 5

For a child or children who require transport as part of a multiple patient transport (newborn with mother, multiple children, etc.)

The NHTSA recommendations were written with the “ideal” solution in mind for each situation, meaning it meets the ultimate goal of safely and appropriately transporting children in ground ambulances. But knowing the number and variety of devices available, the authors also provided a backstop for each of the five situations.

“‘If the Ideal is not Practical or Achievable’ is also provided in each of the five situations—this recommendation provides guidance to EMS professionals for the safe transportation of children if the Ideal cannot be achieved. For the situation involving the transportation of a child who is uninjured and/or not ill, a third recommendation for safely transporting the child, ‘If Resources are Limited,’ is also presented.”1

Going further, the NHTSA working group also stated its consensus that it is not appropriate to transport children, even restrained, on the bench seat located in the rear of many ambulances.

Included in its recommendations, the NHTSA working group noted some inherent limitations, namely that local, state and national EMS organizations all have their own protocols and guidelines they must operate within. The working group also stated its efforts did not include recommendations of specific child restraint devices or assessments of ambulance design and crashworthiness, among other considerations.

“I’m a paramedic, I still work with a volunteer service here in southeast Iowa—we want the down and dirty, let me know what it is I need,” she says. “I take great pride that as a workgroup in the five different situations we put forth we were able to address that. That, if you have a child who’s x, y or z, this is the ideal way you should restrain them. And if that is not feasible or practical, here’s some other practical ways that can potentially achieve that same goal.

According to Altenhofen, the options under any situation can range from commercial child seats to a number of EMS-specific devices. Each device has its pros and cons, not the least of which is many of them can only accommodate children up to 40 pounds, or aren’t built for infants. In addition, while some devices are lightweight and easy to store, others—like commercial car seats—are bulky and impractical for regular use on an ambulance, if they’re even recommended by the manufacturer for use in the emergency transport setting at all. And, there’s also the cost. Some devices are only available in new ambulance construction, making it an expensive proposition to ensure every ambulance in service at a given agency is properly equipped. EMS providers must not only look at the instructions of use for the transport device but also for their stretcher and assure that the instructions for their specific stretcher allows such a device to be used on it.

“But that flexibility has also left some room for confusion,” she continues. “If you went to EMS providers in a bunch of different states and asked, ‘What kind of child restraints do you need in an ambulance,’ they’ll probably all say they’ve got to meet Federal Motor Vehicle Safety Standard No. 213. Well, no, you can’t, because that’s a motor vehicle standard, not an ambulance standard. However, we do want that restraint device to meet the crash criteria and the injury index of Federal Motor Vehicle Safety Standard No. 213, so we know if that ambulance crashes this device is going to keep that child as safe as a conventional child safety seat in a regular passenger vehicle would.”

A Glimpse at the Future

In Altenhofen’s perfect world, there would only be one restraint device for everyone.

“I have said numerous times at different local, state and national meetings, it would be nice if we had a cot that had the ability—no matter who you are, how tall you are, how wide you are—to have a five-point harness system that would fit any person,” she explains. “So it wouldn’t be that it’s just a pediatric device or just an adult device, it is a restraint device that is non-age specific. I could lay on that cot and at 5’11” and 125 pounds you could restrain me, but you could also restrain my husband who is 5’11” and 275 pounds or the kid down the road who’s 8-years-old and weighs just 75 pounds. That would help so much in an EMS environment, because it’s fewer things for providers to have to train on, less equipment they have to think about and work with, etc.”

In the real world what we’re left with are a number of possible pediatric-specific solutions, none of them perfect—yet—but we are getting there. Altenhofen says she hopes in her lifetime we see an ambulance design standard and a testing standard that addresses safety issues for patients as well as the providers working in the back of the rig.


  1. National Highway Traffic Safety Administration (NHTSA). Working Group Best-Practice Recommendations for the Safe Transportation of Children in Emergency Ground Ambulances,
  2. Bull M, Weber K, et al. Crash Protection for Children in Ambulances,
  3. Levick N. Objective Safety,
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