When a new ambulance is built in this country, the manufacturer must adhere to state or national safety standards that prescribe criteria for passenger restraints, cot retention and equipment storage, among other things.
No safety standards currently exist, however, for so-called "remounts": a recycled ambulance box installed on a new chassis.
That is, unless you are in Virginia.
The Virginia Office of Emergency Medical Services (VAOEMS), under the direction of Michael Berg, manager of regulation and compliance, has recently affirmed existing regulations that require refurbished or remounted ambulances to meet the same safety and quality standards as newly constructed ambulances.
Virginia is the first state in the country to hold remounters to these exacting standards.
"We feel that patient and provider safety is paramount," Berg says. "We are obligated to protect them to the best of our ability."
Berg was initially approached by his field staff inspectors, who wondered why remounts were not being held to the same standard as new ambulances. That got the ball rolling.
"We sought an opinion from the state's attorney general's office and found that the language in Virginia's ground ambulance specifications did not delineate between new construction and remounts, and as such, all must adhere to the same standard," says Berg.
With the advent of scientific research, crash testing and other technological advances, the ambulance industry has more safety data than ever. Using test results from the National Institute for Occupational Safety and Health (NIOSH), the Society of Automotive Engineers (SAE International) and National Institute of Standards and Technology (NIST) established safety and design specifications to improve safety for all those involved in an ambulance transport.
Virginia's remount standard includes the SAE's requirement that ambulances successfully demonstrate the integrity of both cot retention and restraint systems in frontal and side-impact collisions. While this testing requirement may prove expensive and inconvenient for independent remounters, Berg remains committed to his state's decision.
"How can you argue proven research safety?" he says. One agency in Virginia, the city of Roanoke, recognized that the cost of these new standards was not prohibitive. Berg says the system's leaders showed the city's risk management group that the cost to install cot retention systems would be far less than paying for one disability.
As Virginia takes the lead on this issue, the two primary organizations that write ambulance safety standards (NFPA and CAAS) are also convening work groups and committees to address remounts. The NFPA (National Fire Protection Association) recently appointed Berg as chair for its work group as it embarks on the process.
NFPA's 1917 Standard for Automotive Ambulances addresses the design, testing and performance of new automotive ambulances and currently updates on a three-year cycle. Ken Holland, a senior emergency services specialist with NFPA and staff liaison to its ambulance technical committee, says the first draft of the 2019 edition of NFPA 1917, which includes changes relative to remounts, is open to public comments now and until May 10, 2017. The committee will soon decide whether there should be a new document or a revision to the existing one.
Mark Van Arnam, who is the administrator for the Commission on Accreditation of Ambulance Services' Ground Vehicle Standard (CAAS-GVS), is planning a remounter forum June 7 in Charlotte, NC. At the forum CAAS will collect data and receive input from vendors, regulators and operators to help develop standards for remounts.
"Right now there are no standards for remounted ambulances, no collection of information on who does remounts, and no way to keep track of how many there are," Van Arnam says. "It is our hope that our forum will be a first step to improving this issue."
Van Arnam's statements reflect a strong commitment among those involved with ambulance safety: that it is important as an industry to establish compliance for remounts and that states should adopt and enforce these new standards. Ultimately, all parties involved—from manufacturers to remounters to patients, providers and managers—should demand the changes necessary to make everyone safe.
Berg points to some "nightmare stories" about unsafe practices and their effects on the business of ambulance building.
"If the industry as a whole were to take a serious look, it is clear they'll want to produce a product that is safe, so their customers will come back," he says.
The Patient Safety Parallel
A parallel can be drawn to the improvements made in patient safety over the years. Medical treatment and EMS policies and procedures are continually evolving and improving, while worker safety has lagged behind in terms of advancements. Berg argues that the changes in healthcare, service delivery, response-time standards and the like are similar to the changes in ambulance design and safety.
Part of making an ambulance ride safer is striking a balance between how much a provider treats patients and accomplishes on scene versus in the back of the ambulance. Safety for all passengers will likely be improved by reducing the need for a provider to unbuckle and stand up while the unit is rolling down the road with lights and sirens.
"For the majority of patient encounters, the days of 'scoop and run' are coming to an end," Berg says. "We really have to examine the way we do business. Just because we've done it this way for 40 years doesn't mean it is correct."
Hilary Gates, MEd, NRP, is a paramedic in Alexandria, VA. She is an EMT instructor and teaches in the School of Education at American University. She began her career as a volunteer with the Bethesda-Chevy Chase Rescue Squad. Gates has experience as an EMS educator and symposium presenter and is involved in quality management and training for the fire department.