Ray Barishansky is a featured speaker at EMS World Expo 2015, scheduled for September 15–19 in Las Vegas, NV. Register today.
In the past, sentinel documents released by the National Highway Traffic Safety Administration (NHTSA), such as the EMS Agenda for the Future and the National EMS Educational Agenda for the Future, have given providers, educators, managers and others a look at what the future of EMS could be. Similarly, two recent publications from the Science and Technology Directorate (S&T) of the Department of Homeland Security (DHS) have the potential to educate the EMS community on best practices and offer a mandate for change.
Every day, we read of tragic accidents injuring or killing, EMS providers and the patients they serve. Seeing a true need for evaluation of best practices, identification of gaps in safe practice and addressing of these gaps with input from industry stakeholders, DHS has taken the lead on putting together documents that speak to critical needs in the EMS community, specifically ambulance operations and patient compartment safety, and compiled two documents with significant best practices for the EMS community to examine and implement.
Ambulance Operations Document
The first document, A Research Study of Ambulance Operations and Best Practice Considerations for Emergency Medical Services Personnel,1 released in April 2015, dissects the critical issues surrounding the current design of our ambulances and recommends improved physical design standards. In attempting to better understand the issues, the team took a multi-pronged approach, including a Human Performance Requirements Analysis (HPRA) to identify ambulance operator task performance requirements, a review of relevant literature on ambulance design and accidents, interviews with EMS personnel from disparate areas of the US regarding operational policies.
Based on the information gleaned from this approach, the team created a list of 49 best practice considerations divided into three general categories: training development, SOPs and communications, and defensive driving. Below are some more specific examples of the recommendations from each of the respective sections:
Training requirements—The Emergency Vehicle Operations Course (EVOC) should be mandated for all drivers. Drivers should also complete supervised on-the-job and annual refresher training. Drivers should be afforded multiple opportunities to learn and practice common driving maneuvers.
Training course refinement—Courses should be updated regularly based on feedback from students and subject matter experts.
Communication devices and protocols—When the ambulance is in motion, operators should minimize communication with the EMS provider in the patient compartment and radio communications with dispatch or the hospital. Communications between the driver and others should be quick and accurate. Ambulance operators should be in communication (verbal, hand and eye) with EMS providers as well as others at the scene upon departing from a parked position.
Lights and sirens—After initial patient care is rendered, the senior EMS professional should assess the patient’s severity and level of stabilization to determine if lights and sirens are needed during patient transport. Use of lights and sirens should be upgraded or downgraded as needed over the course of the transport.
Defensive driving with specific examples including:
Ambulance handling—Operators should become familiar with ambulance handling qualities by driving the vehicle in non-emergency situations, while maintaining optimal vehicle handling qualities. This includes ensuring proper vehicle maintenance.
Management of driver fatigue—Ambulance operators should work to reduce fatigue by getting sufficient rest and following rotating shifts with adequate off-duty time.
Patient compartment awareness—Ambulance operators should maintain awareness of patient safety and comfort and EMS provider safety and effectiveness. Operators should warn the EMS provider in the patient compartment of railroad crossings, rough roads or other environmental factors. They should also convey the operation of turn signals and the presence of the driver’s foot on the brake even if not fully activated.
The document is filled with best practices such as those highlighted above that are easily implementable by EMS agencies and systems across the U.S.
Patient Compartment Factors Document
The second document, titled Ambulance Patient Compartment Human Factors Design Guidebook,2 and released in February 2015 was specifically developed in response to a NHTSA study which indicated that EMS providers experience a fatality rate three times the average national occupational injury rate and cited ambulance crashes and related vehicle accidents as one of the primary threats facing EMS providers.
Additional studies specifically referenced in the document found that both EMS provider and patient deaths and serious injuries occurred at a high rate within the patient compartment of the ambulance during transport. These incidents were often related to factors such as EMS providers not using restraint systems (such as seatbelts), improperly restrained patients and structural design deficiencies.
This document began with the objective of centralizing and eventually standardizing a best practices approach to ambulance safety gathered through observations and discussions with users, focus groups and surveys. From this list of needs, design requirements and guidelines were developed. Based on reviews by EMS providers, manufacturers, and other EMS community representatives, the design concepts, requirements and guidelines were updated and finalized.
This process has resulted in a comprehensive list of design guidelines and best practices for ambulance patient compartments that fulfill the needs and requirements of a wide range of EMS provider organizations. Of these requirements and guidelines, those that were suitable for standardization were proposed for inclusion in the upcoming version of NFPA 1917.
Based on the information gleaned from this approach, the team focused on the following topics associated with patient compartment design:
Human factors engineering
Seating and restraints
Equipment and supplies
Ingress and egress
Specific examples of the aforementioned analysis are below:
Equipment and Supplies
The document highlights that it is critical to properly determine the amount, type and location of equipment and supplies carried on the ambulance to optimize the level of patient care that can be provided, while maintaining a safe environment for both EMS providers and patients. The patient compartment should be designed for easy access to equipment. Items that are crucial for performing patient care need to be determined based on the type and frequency of calls that the organization performs, as well as state and local regulatory requirements.
Specific considerations regarding equipment and supplies include:
ALS versus BLS level of service.
Frequency and criticality of equipment and supplies.
Stabilizing patient at scene versus in the ambulance.
One of the more interesting areas covered in this section is specific to reducing the risk of injury in the back of ambulances. These best practices focused on securing of all equipment, routing of cords, leads and tubing and having adequate space for EMS providers to move about.
Keeping in mind the need for both safety and accessibility while treating a patient, the Guidebook offers recommendations including:
All items required by EMS providers to provide effective patient care should be capable of being identified and accessed by EMSP while seated and restrained
All items inside storage compartments must be within reach of the smallest female EMS providers (5th percentile in stature and arm reach).
EMS providers reach to a storage location must also not be blocked by structures, equipment or elements of patient care equipment (e.g., wires, cables, tubing, IV bags).
EMS providers must have an unobstructed line of sight to the storage location to visually identify the correct storage compartment.
The guidebook then discusses specific considerations regarding storage include working out of First-In Kits versus on-ambulance storage as well as minimum versus maximum equipment and supplies.
Ingress and Egress
This section discusses design considerations that will ensure safe and effective ingress and egress of EMSP and patients in all weather conditions and without undue strain on the provider. It also highlights some of the major areas where EMS providers have the potential to injure themselves when entering or exiting the vehicles and builds on the assertion that providers must be able to safely and effectively load and unload patients as well as enter and exit the ambulance. Specific examples are below:
Doors—All doors should have a failsafe method of opening and should not be lockable in a way that precludes egress from the patient compartment during an emergency. Door handles should be able to accommodate a wide range of hand sizes.
Steps—Step sizes, step height and tread depth are all outlined, as is the need for steps to be grated and well-lit.
Windows— Windows should allow EMS providers to see potential obstructions or unsafe conditions before opening the door.
Handholds and Handrails—Location of handholds/handrails as well as size of handholds/handrails are discussed.
This section also covers ingress and egress in both normal and adverse weather conditions.
The documents that DHS has taken the lead in developing and promulgating are full of best practices for EMS agencies to utilize as they develop their own individual policies and processes related to the various safety elements these documents focus on. It is also up to regional and state regulatory entities to review the documents and assure that their guidance as current as possible and based on the safety of the providers that serve their systems.
Raphael M. Barishansky, MPH, MS, CPM, is director of EMS for the Connecticut Department of Public Health. A frequent contributor to and editorial advisory board member for EMS World, he can be reached at firstname.lastname@example.org.