Last summer saw the publication of Change Notice 8, the latest modification by the General Services Administration (GSA) to its longstanding KKK-A-1822F federal ambulance specification.1
Changes in this most recent document include the embrace of a pair of recent recommended practices from SAE (the Society of Automotive Engineers) International: 1) that all patient compartment seating conform to SAE J3026, which addresses seating integrity and occupant restraint, and 2) that ambulances have a complete litter fastener assembly that meets the performance requirements of J3027 for litter integrity, retention and patient restraint. These guidelines set out the crash forces patient compartment seats and cots must withstand: 22.5 Gs in a frontal impact and 26 Gs in a side impact.
That document is one of many recent indicators that the ambulance industry and its partners are paying increasing attention to the issue and aspects of safety in its oh-so-ironically-unsafe mobile workplaces.
“We’re seeing that, as I think everyone is,” says Jerry Socha, director of marketing for Ferno, a major industry provider of cots, stair chairs and other ambulance components. “There have been a lot of studies done over the last 5–10 years, and we’ve all seen the NHTSA data on the rate of ambulance crashes and how that plays into the injury rate and death rates. We know those rates are high when you compare EMS to other occupations, and when we look at the root causes of it, a lot of it comes back to the ambulance and ambulance environment.”
There’s not a single measure that can fix that, but a whole lot of best practices we’re still deciphering and trying to broadly implement. It’s seemed like slow going sometimes, and for good reason.
Agencies should want safer rigs on the road, but improvement costs money. Providers know it’s a dangerous ride but don’t always cotton to the tools that reduce their risk (e.g., driver feedback systems, restraints at all times). Makers want live customers who keep buying but must ultimately respond to what buyers want and can afford. Government has been slow getting started but is striving to catch up.
It finally feels, though, like we’re getting someplace in the area of safety.
“We’ve seen that trending—safety is the biggest thing in the discussion as of late,” says Scott Sawatsky, VP of sales and marketing for manufacturer Crestline Coach. “The standards are changing to drive improvements both to the body itself and also the interior equipment—cabinets, seating, cot retention, etc. That’s on a lot of people’s minds.”
After Change Notice 8 arrived, Ferno’s Steve Rowland gave it the once-over for the Fire Apparatus Manufacturers’ Association (FAMA).2 He noted that “the take-away from these SAE-related changes is that the rear compartment seats and cot fasteners used in the past will likely not be compliant with the new guidelines.”
That’s particularly pertinent to those using trucks that still have squad benches and basic lap belts. Designs with captain’s chairs and four- or five-point harnesses will have an easier time achieving compliance.
That’s a direction in which many have already started.
“We are seeing more and more customers move away from traditional bench seating and opting for safety seating,” says Benoit Lafortune, co-owner and executive vice president of Demers Ambulances. Demers’ answer is its Mobility Sliding Seat design, an ergonomic captain’s chair that swivels and moves both front to back and laterally, allowing users to remain safety restrained while they tend to patients. “Critical equipment and supplies remain accessible from that seat-belted position,” Lafortune notes, “enabling the paramedic to focus on patient care.”
Crestline reports the same: “We’re starting to see a slow demise of the traditional squad bench, although there are many reasons why people like working on them and may still utilize them in their design,” says Sawatsky. “I think we all know it’s something that needs to eventually go away, but until we do that, you need a proper design inside: a workspace and environment where medics can stay seated and belted and still have access to the equipment and supplies they need during the call.
“That’s the biggest challenge: to deliver an environment that’s safer and more ergonomically conducive. If you don’t do that, medics will resort back to their old ways of working. So that’s the challenge for us.”
All the recent testing and attempts to better inform ambulance-industry standards and guidance with scientifically sound evidence and research haven’t gone unnoticed either. Customers are increasingly looking for that kind of validation.
“We are seeing more and more customers requiring scientific data and safety test results from manufacturers as part of their bid requirements,” says Lafortune. “We’re strong believers in product testing and are pleased to see EMS agencies move in this direction.”
The SAE guidance is also cited in both of the main U.S. ambulance industry standards documents: the 2016 revision of NFPA 1917 and the inaugural Ground Vehicle Standard from the Commission on Accreditation of Ambulance Services (CAAS).
‘A Lot More Dialogue’
Those are national standards but of course don’t apply to everyone. Only around 30 states, for example, have adopted the KKK specifications wholly or partly into law.
Still, they represent a consensus embrace and de facto conventional wisdom for the U.S. And while things here aren’t optimal and can vary by state and locality, that kind of national codification can actually be a cause for envy, even in advanced locales.
“The U.S. has a bit of advantage in that you’ve got a national standard—NFPA and CAAS now, and still the AMD Triple-K standard,” says Sawatsky. “But there’s a lot more dialogue in the U.S. going on across the board, I think. In Canada it’s still very jurisdictional-based, and I think that’s something that there’s a desire to look at” and potentially reform.
Observes Rowland: “The beauty of these documents referencing the same SAE-recommended practices is that the manufacturers of seating and cots are able to design and test to one solid standard, and ambulance manufacturers do not need to build ‘state-specific’ ambulances to provide these integrated options.”
That’s not to say the bar is lower in Canada. There, like here, the bar’s height varies.
“There are more strict standards in Canada,” Sawatsky adds. “[The changes in Change Notice 8] aren’t a huge departure from where Crestline is at. One of our advantages is we deal with some pretty strict standards—Ontario, Quebec and Alberta are the three primary provinces that kind of drive the safety standards here. Some of that we’ve had to build to over the years, and then you tap into the European standards we’ve built to at times, and it’s kind of encompassing. We’ve adopted some of those technologies into our normal ambulances, whether we distribute them in Canada or the U.S. It becomes part of our standard product offerings.”
Elsewhere, in Canada and the U.S., forward-thinking organizations and agencies can adopt key standards even without mandates from governing bodies.
“I see EMS services just going ahead and adopting them anyway,” Sawatsky says. “They’re not necessarily waiting for the standard to change; they’re already starting to adopt what other jurisdictions are doing. There are good examples of that up here in Canada and across the board. So although the standards may not be where they could be, customers are already making better choices. They’re doing their own research and making better decisions and driving improvements.”
Where the Medic and Patient Are
The idea of safety has driven some big innovations from Ferno, which clearly has designs greater than being just a cot company. Its recently launched iN∫X integrated patient transport and loading system all but eliminates lifting while loading and unloading patients, and a new inline fastener due this spring reduces that burden to nil.
“When the iN∫X is used with the inline fastener, there’s zero lifting—all the weight is born by the ambulance and the iN∫X,” Socha says. “There’s nothing the medic is holding at any point throughout the loading and unloading cycle.”
A white paper from researchers at Ohio State University found that even without the fastener, the iN∫X effectively eliminates lifting. It’s still new enough that the evidence is anecdotal, but harder data are being developed.
“From the customer conversations I’ve been having, those who have transitioned to the iN∫X have seen almost immediate reductions to their injury and worker comp rates,” says Ferno PR chief Heather Martin. “One agency told me, as of December 2014, they had nine guys out with injuries, and three weeks after implementing the iN∫X—they have seven trucks—they had none. So that’s anecdotal; we can’t exactly quantify it yet, but I think agencies are very happy with the reduction of injury rates they’re seeing.”
Coming next from Ferno is its audacious iN∫TRAXX concept: an integrated vehicle component system designed to secure loose equipment in the patient compartment and allow medics to deliver care while seated and restrained.
It’s a modular system that uses wall-mounted tracks to secure equipment mounts, storage cabinets and soft-sided supply bags where customers want and providers use them. Having needed goods within arm’s reach can eliminate the need to unbuckle and stand to retrieve them in transit. Supplies and equipment are interchangeable across vehicles and vehicle types, and it’s all compliant to SAE J3043 (which covers ambulance equipment mounting) and can withstand a 26-G crash.
“Fundamentally it’s about making sure medics can stay safely seated and restrained while delivering care,” says Socha. “To do that we need to create an environment where medics do not have to get up and reach around for their supplies. So the track environment, with the modular components, allows us to bring everything to where the medic and patient are.”
Several ambulance companies are doing builds with the iN∫TRAXX, and wheels are already on the road in select locations. Missouri’s Pulaski County Ambulance District has had a beta version in an Osage Ambulances truck since last year.3 (That ambulance, on a Sprinter chassis, also eliminated the bench seat.) And Crestline used it in its new ICON 2.0 next-generation ambulance developed for Ontario’s Frontenac Paramedic Services. A 90-day beta trial recently concluded there.4
The ICON 2.0 uses the new Ford Transit cutaway chassis and incorporates the iN∫X, iN∫TRAXX and associated SAFEPAKs, as well as Ferno’s AceTech vehicle intelligence system.
The Transit is not yet ready for mass production, but “there are good signs that it’s going to be a platform, once they do some changes to the weight capacity, that will be a good selection in the future,” says Sawatsky. The iN∫TRAXX provides flexibility and ergonomics, he notes, and “in a nice, smaller envelope.”
The iN∫TRAXX will officially be on the market at the end of June, but Ferno is taking preorders now and can supply builds.
Those are just a few aspects of what seems to be a growing, maturing safety culture in the world of EMS. “The idea that ‘we’ve never done it that way before,’” Rowland wrote, “will soon be a call to embrace new ideas rather than reject them.” With a solid evidence base, of course.
Future directions likely include further digitization of the ambulance, enhancing connectivity with partners and facilitating fleet and inventory management.
“We believe the ambulance of the future will transition from a connected vehicle to a smart vehicle utilizing new technology and systems,” says Lafortune, who urges buyers to consider AVL technologies as part of all new vehicle purchases. “These new systems will provide proactive feedback to fleet managers, EMS directors and paramedics to improve efficiency, safety and overall operations.”
“From behind your desk you’ll be looking at your monitor and seeing your entire fleet,” says Sawatsky. “You’ll know what needs to be maintained, where it’s at, if there’s a cycle or unit coming up that needs to be serviced, and you can see that all at your fingertips in real time. That’s a powerful tool to put information in your hands at any given moment.”
Ultimately, “Safety has a lot of different aspects,” says Socha. “Fundamentally it’s about a culture of safety and having the right mind-set and behaviors. But we also have to create the right tool set that supports a safe set of practices, behaviors and mind-sets. We want to make sure we’ve fully addressed the entire delivery-of-care environment from top to bottom.”