EMS World Roundtable: Ambulance Safety and Innovation

Sprinters are spreading, side-facing bench seats saying sayonara. Slowly and fitfully, belatedly for sure but now indubitably, we’re sprucing up the safety of the ambulance environment.

Of course that covers many aspects, and in many there remains ground to make up. There’s always resistance; the next big battle will concern remounts. But the participants in this month’s EMS World Roundtable largely see things getting better in the ambulance world, driven by better science.

“I think we have an opportunity that wasn’t available to us before,” says Mike Berg, BS, NRP, manager of regulation and compliance for Virginia’s Office of EMS. “Historically we’ve bought and used what was out there because that’s the way we’d always done it. If research and data now show us what we’re doing isn’t appropriate, we should embrace that and implement change.”

With remounts Berg’s office may have inadvertently triggered a big one. As detailed elsewhere in this issue (and at www.emsworld.com/12313412), some OEMS field staff wondered why remounted ambulances in the state weren’t held to the same standards as new ones. The state attorney general’s office reviewed state law—which doesn’t distinguish between new trucks and remounts in requiring compliance with GSA’s KKK-A-1822F specification—and decided they should be.

The impact of this interpretation could be big. It spurred some pushback among secondary remounters, but original manufacturers have been largely supportive. “In fact,” says Berg, “we heard from several that this is an area we need to address as an industry.” Taking the cue, both CAAS and NFPA will now start developing remount standards. 

That’s one topic discussed by this month’s panel. While these four experts were not interviewed simultaneously, their questions were similar and responses are therefore presented roundtable-style.

The Panel:

Michael D. Berg, BS, NRP, is manager of regulation and compliance for the Virginia Department of Health’s Office of EMS. He chairs NASEMSO’s Agency & Vehicle Licensure Committee and represented NASEMSO on CAAS’ GVS steering committee. He is also a member of NFPA’s technical committee on ambulances.

Chad Brown has been vice president of sales and marketing for Braun Ambulances since 2012. He previously served as a regional and executive sales manager for the company. He is an alternate member of NFPA’s technical committee on ambulances.

Ron Thackery, BA, JD, is senior vice president of professional services and integration for American Medical Response, overseeing safety, fleet administration and risk management. He represented the American Ambulance Association on CAAS’ GVS steering committee and is a member of NFPA’s technical committee on ambulances.

Mark Van Arnam is the administrator of the Commission on Accreditation of Ambulance Services’ Ground Vehicle Standard (GVS v.1.0). He was the founder of American Emergency Vehicles and served as its CEO from 1991–2016. 

What do you see as the implications of the Virginia remount interpretation?

Van Arnam: The remount business is growing. Part of the reason is economic; modular ambulances have been sold since the beginning as vehicles that could be remounted on new chassis. It allows you to have a new ambulance, so to speak, without spending 100% of the price. The problem is that these remounted ambulances, as they increase in popularity, are exempt from standards! There are basically no specific standards for remounters or remounts. Contrast that to the new-vehicle side, where both the final-stage ambulance manufacturers and their products require credentials, certifications and compliance to various standards. So in that respect I think it’s very timely to ask what can happen here and how we can bring everyone under the umbrella and say there is a need for some standards for remounters and remounted vehicles. 

Brown: The implication of the Virginia ruling could be rather drastic. I think you won’t see Virginia vehicles being remounted, in my opinion, just because of the testing that has to go into it. It’s impossible to do. Some of the dynamic testing that’s required in the new builds, you can’t duplicate that in an existing box and then remount it. You physically damage the box—you just would not be able to do it. So I think you’ll see new truck sales go up and remount sales go down.

Berg: Some of the secondary manufacturers have called and complained. One said I was trying to put them out of business. They couldn’t afford to take the truck out of state to do a roof crush test in order to meet the standards. But in talking to people, I’ve found the original manufacturers don’t have an issue with it. If you’re an authorized vendor or dealer for them, they’re willing to stand behind their product. But if you’re not affiliated or an authorized dealer, there’s some hesitancy from a liability standpoint.

What other big trends are influencing ambulance purchasing and design today?

Brown: I think safety is No. 1. With the new SAE testing requirements in all three industry specifications [KKK-A-1822F, NFPA 1917 and CAAS GVS], that’s going on at the manufacturing level, and they’re building more safety and regulation into the ambulances. That’s the biggest driver as we talk to people: design layout and ergonomics. 

Thackery: One is whether there is knowledge on the part of the buyer or the ambulance upfitter of advances that have been made in construction of the patient compartment with respect to seat restraints, cot restraints, patient restraints, equipment mounting and cabinetry. And instrumental in that decision is the cost of the advances being made as a result of the science that’s out there. I don’t know that people fully appreciated the cost impacts of those improvements in safety.

Van Arnam: We know the ambulance is a very difficult work environment and historically a very dangerous place to be for the crew, so the focus on safety is timely and very much needed. The work that’s been done by NIOSH to develop the SAE standards is nothing short of revolutionary. It’s some of the only real science our industry has ever had.

Berg: I do think some people are having a hard time letting go of tradition. I spoke at a conference in another state last week, and I noticed the ambulances being displayed there still had CPR seats in them. The majority still had bench seats. A lot of people are still married to that bench seat—they’re not quite used to having the forward-facing seat and work station. I guess it’s just hard to let go of tradition.

With the CAAS GVS and NFPA 1917 standards for ground ambulances and the Star of Life specification not gone yet, we don’t seem any closer to having a single defining standard for ambulances. Do we need one? Or can the multiple efforts we have today successfully coexist?

Thackery: I think the Triple-K, GVS and 1917 all recognize the importance of safety and means to incorporate features that would improve it. There are a few that may be experimental, but they’re aimed in the right direction. And really, it’s remarkable how consistent those standards are, rather than being divergent. I think that’s driven in large part by the scientific work done by Jim Green and NIOSH.

Van Arnam: I think the NFPA developed an excellent standard. EMS is a very broad industry with multiple market segments. We had some organizations with an interest in a standard that wasn’t developed by the fire service that came to us in 2013 about developing a standard for the rest of the industry, so to speak—the non-fire segment. That’s the private providers and nonemergency side, the hospital side, the air medical side—there are quite a few segments to the market besides the fire side. CAAS developed our standard in response to requests from these other segments of the EMS market.

Having said that, on a go-forward basis, I think it’s likely and reasonable that the standards coexist. We’re already seeing states considering accepting both. Alabama is the first to accept the Triple-K, CAAS-GVS and NFPA, and you as a user can decide which to use! So EMS providers can decide whether they want one standard or another based on individual need.

Brown: Can all three of them coexist? Absolutely—they’re coexisting as we speak, and we’re building to all three specs. Selfishly, from a manufacturer’s position, having a unified specification that all builders build to and all customers buy off would be tremendously more efficient for us—with regards to testing, with regards to documentation and reporting. Ultimately maintaining three specs, with little differences between them, requires additional administrative work, which adds cost and time to the vehicle.

Several jurisdictions are fielding stroke ambulances now, and more commonly specialized units like critical care trucks, bariatric trucks, etc. What’s the future for these more specialized vehicles? 

Brown: We’re starting to see an increase in requests to build specialty vehicles. The challenge is that the state EMS directors need to work with the manufacturers through NASEMSO to define specifications for them. Right now we don’t have those, and I think that’s a loophole in some cases. If you have a specification, we’re all building to the same requirements, so that’s the best of all worlds.

Berg: In rural and frontier areas, I don’t know you’ll necessarily see the value of those types of vehicles from a cost and utilization standpoint. There will be a growing trend for the availability of critical care transportation, where they’ll have some more effective diagnostic tools and drugs and therapies and will be reaching out to community-based facilities to bring those patients into the high-level services.

Thackery: A stroke unit is pretty specialized compared to what is a relatively small number of highly critical patients. Developing a particular ambulance for a low-volume activity is hard to sustain in EMS. Some communities are doing it, though, and I think we’ll continue to experience development in regard to patient care and what can be done to most effectively improve the condition of the patient.

Among those emerging needs could be greater use of telemedicine technologies as part of mobile integrated healthcare and community paramedicine, among other reasons. How will this impact our trucks? Is mobile technology sufficient for what we’ll need?

Thackery: It’s going to become much more common. Most ambulances today are already hotspots, so they have Internet connectivity and can transmit a variety of information. We have the ability to utilize a cell phone camera and video, to utilize a GoPro or even a mounted camera in the back of a unit, although you have to deal with some HIPAA issues there. But the technology is available. Exactly what the process should be is probably still in the developmental stages. But we partner with one of our sister companies, Evolution Health, which has two medical command centers, one in Dallas and one in South Florida, that are essentially licensed practices of medicine. They use telemedicine to assess and diagnose and prescribe medications for patients. So as far away as that might sound, I think it’s relatively close. 

Van Arnam: I think for the most part the technology will be add-on technology. Because it varies from area to area and provider to provider, people are bringing their own technology to the vehicle, rather than the vehicle delivering the technology. The good part of that is that it allows change. An average ambulance is going to operate for 8–10 years, and technology changes at light speed compared to that.

Brown: We’re evolving with regards to electronics installs, integration of the different electronics across silos of information in the vehicles, and how we get that to where it needs to go. That means long preconstruction meetings, where you’re now bringing in IT personnel from the hospitals to be part of the conversation. It’s a different type of installation. You have to bring all the right people to the table who know their systems inside and out.

A few years ago NHTSA published some recommendations, but there remains lots of concern about the transport of pediatrics. What are the most important steps we can take to make ambulances safer for children?

Thackery: I know there’s quite an interest there, and we should expect something to occur. I do think there are probably better ways to transport pediatrics. Because to say pediatrics is to use one term to describe what may be up to 10, or maybe more, types of patients, based on size or weight or age or height or any of those factors. Regardless, I do believe, and I think NHTSA understands, that there is a good bit of research that needs to be done so any guidance provided is based on science.

Berg: I know NIOSH was asked if they could do some testing like they’d done with the ambulance cots, but NIOSH’s focus is worker safety. We’ve struggled with this for years. Even today, when we have a precipitous delivery in the field, where do we put the newborn? We put the newborn with the mother on the cot! Our state law says they have to be in an infant carrier, but many services don’t carry infant carriers. So it becomes a challenge of space and practice and culture. We need to have somebody step up and provide the funding so the testing can be done and a national standard developed.

Van Arnam: We’ve seen providers buying a variety of child seats at WalMart and strapping them in; we’ve seen neonatal transport devices secured with bungee cords, cargo straps and everything from A to Z. I think there’s little doubt the next wave is for someone to fund projects on safety standards for transportation of peds, both as patients and as passengers. That will require a lot of money and time, but some minimum standards are sorely needed. 

You need to let the market run with it. But particularly the neonate side is a small market, so it’s hard to get a broad interest from manufacturers. That’s a big part of research and product development: getting the manufacturers interested, getting them to come across with R&D dollars and develop effective and competitive products the industry needs. That’s a shortfall.

What other changes, improvements, technologies or innovations do you see coming to the ambulance environment in the next few years?

Berg: I think the use of the large boxes will continue to decrease. If services look at their call data and the services they’re providing, I think they’ll find a large percentage of the work they’re doing can be handled in the traditional Type II ambulance. And with the science that’s out there now, I think we’ll see smaller, more sophisticated equipment that’s able to be housed safely in the vehicle. 

Brown: I think you’ll see some different interior configurations and the specialty vehicle market grow. The mobile stroke units, critical care transports, neonate transports—all of those things will be defined as specialized so we have a standardization across the board. And from an innovation standpoint, there are some driving technologies with regards to how we prevent accidents—the “guardian angel” [advanced driver assistance system] stuff we can explore as it’s becoming available. Vehicle diagnostics, being able to communicate back to a fleet manager or chief that a vehicle that has low tire pressure—all that is coming relatively soon. You’ll see something from us at FDIC this year with regards to that.

Thackery: I think we’ll see many of the technologies that have been incorporated in passenger vehicles make their way into the commercial van and truck space, where they’re standard instead of options. With operations like lane changes, following other vehicles, determining spaces in front of or behind your vehicle, we’ll have the benefit of that automation, which will improve safety.

Who’s Up Next? Possibly Peds

It’s not news that the safe transport of pediatric patients is on the radar of EMS leaders. NHTSA published its Working Group Best-Practice Recommendations for the Safe Transportation of Children in Emergency Ground Ambulances back in 2012. NASEMSO has a Safe Transport of Children committee that meets monthly. The EMS for Children Innovation & Improvement Center offers a number of resources for safer movement of our littlest patients. 

“Aside from the remounts, I think pediatrics is the next big wave of things that need to be addressed in EMS,” says Mark Van Arnam, administrator of CAAS’ Ground Vehicle Standard. “Right now we’re transporting a wide range of ages and sizes, both as patients and passengers, with no standards per se. I think there’s great interest in developing those.” 

NHTSA’s recommendations cover five areas: kids who 1) are uninjured and not sick; 2) are injured or ill but don’t require continuous or intensive monitoring/interventions; 3) require continuous or intensive monitoring/interventions; 4) require spinal immobilization/lying flat; and 5) are part of a multipatient transport (multiple children, newborn with mother, etc.). 

Each group has an “ideal” recommendation, with some next-best steps suggested if that isn’t practical or possible. 

• NHTSA document: www.ems.gov/pdf/811677.pdf;  
• NASEMSO committee: www.nasemso.org/Committees/STC/index.asp; 
• EMSC IIC: https://emscimprovement.center/.

The Smart Ambulance Project

Unnecessary ambulance transports aren’t just a problem in America. In Europe they’re a prime reason behind the Smart Ambulance project.

The Smart Ambulance: European Procurers Platform (SAEPP) consists of various European ambulance services, research groups, hospitals and other healthcare organizations working to create an upgraded emergency ambulance that will let prehospital providers provide more high-level patient care on-scene, avoiding some transports.

Their goals in designing the truck include maximizing space, minimizing infection risk, streamlining hospital admissions and handovers, reducing costs and, most important, providing a safer environment for providers and patients both. The project is still in its early consultation stages.

“There are many problems with the design of existing ambulances that impact negatively on patients and frontline ambulance clinicians alike,” project leaders note. “Some of the most pressing issues concern the treatment space in the back of the emergency ambulance. This environment is difficult to keep clean, given the frequency of use, and the resultant lack of opportunity to scrub the vehicle down can lead to hygiene and infection control problems. Ambulance crews also suffer from poorly thought-out ergonomics, badly laid out equipment and difficult-to-access storage spaces, all of which can affect performance in critical, life-threatening situations.”

For more: https://www.smartambulanceproject.eu/.