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Jennifer Marshall

Health Care

Safety Standards for Ambulances—STAT

Sit down and buckle up!

Published: Thursday, May 26, 2016 - 13:46

For as long as we have had automobiles, we have had traffic accidents. Even the vehicles that we depend on to take care of us in the event of an accident—ambulances—get into accidents nearly every day. Because ambulances are basically a small emergency room on wheels, the occupants in the back are at perhaps even more serious risk of being injured, or killed, during an accident than people in other vehicles. This is especially true when you consider that ambulances are often weaving through traffic at high speed on the way to the hospital.

According to a 20-year National Highway Traffic Safety Administration (NHTSA) study, there are an average of 4,500 crashes involving ambulances every year. Of those crashes, the report found that 84 percent of emergency medical service (EMS) providers in the patient compartment weren’t wearing a seat belt or some other restraint. The report also found that 44 percent of patients were ejectedfrom the cot in serious crashes.


Ambulance accident infographic from the NHTSA. We join them in calling for EMS providers to “Sit down, and Buckle Up!” Click here for larger image. Credit: NHTSA

Obviously, this raises a number of serious safety concerns for providers and patients.

If you’re lucky enough to have never seen the inside an ambulance, let me give you a general idea of what you would see in one. There’s a cot, usually a bench seat on the curb side, a bucket seat at the head of the cot, and sometimes a seat on the side closest to the street. There are communication devices and medical equipment, e.g., cardiac monitors, oxygen, suction machines, cabinets filled with supplies, and needle and trash disposal bins.

When I look at today’s ambulances, what I see is equipment not properly stowed or mounted, slippery floor surfaces, open cabinet doors, lots and lots of sharp edges, and, most important, seating arrangements that don’t allow medical personnel to reach their patients and the supplies they need while seated. Providers feel they have no other option but to stand up and walk around inside the compartment while racing down the highway. Would you want to be standing in your car while moving through traffic at highway speeds?


Ambulance compartment interior after an accident. Ideally, patients, providers, and equipment shouldn't be tossed around like this. Credit: NIOSH

I know I wouldn’t, and unless you’re some kind of daredevil, I doubt you would, either.

Fortunately, this is where standards can have a huge effect on safety and people's lives.

During the past several years, federal, state, and local agencies as well as trade organizations, manufacturers, and numerous EMS professional organizations, came together to develop consensus-based ground automotive ambulance standards. These standards are based on both test methods for crash testing and design elements to make the inside of the compartment more user-friendly and safe.

In March, the Commission on Accreditation of Ambulance Services (CAAS) released its “Ground Vehicle Standard” (GVS v.1.0) for automotive ambulances, and last fall the National Fire Protection Association (NFPA) released NFPA 1917, 2016 edition, “Standard for Automotive Ambulances.” These standards incorporate the Department of Homeland Security (DHS)-sponsored work from NIST and the National Institute for Occupational Health and Safety (NIOSH), as well as many test methods that have been developed by the National Truck and Equipment Associations Ambulance Manufacturers Division and the Society of Automotive Engineers.

Now let me explain how we got there.

The EMS community had long felt that there needed to be a more rational, scientific approach to ambulance design. After all, there had been little significant change since the 1970s, when the EMS community was just beginning to move away from using hearses to transport injured patients. Save that piece of trivia for your next dinner party!


I don't know about you, but I would have mixed feelings about riding to the hospital in an ambulance that looks like a hearse. Credit: Betto Rodrigues/shutterstock.com

Also, because of their size, ambulances didn’t need to meet most of the same crash-testing requirements that apply to our cars. They actually fall in the same category as the shuttle buses at the airport—when was the last time you wore a seat belt in one of those?

The crash-test work NIOSH did during the early 2000s really laid the foundation that we built on. NIOSH conducted four full-vehicle crashes to look at how worker restraints performed, but the testing also revealed other areas of concern related to cot mount strength, seat belt location and seat strength, cabinet location (head impact risk), and lack of equipment mounting.

The good news is that this early testing really helped the ambulance industry better understand the need for standards.

From 2010–2015, NIOSH partnered with the ambulance manufacturing community to conduct crash tests of entire ambulances, cots, seats, cabinets, and equipment mounts. The community voluntarily supplied and paid for all the parts (e.g., cots, seats, cabinets) NIOSH needed for testing. During this time, the partners crafted new test procedures that work for ambulances, while manufacturers tried new designs. Now, the community tests the components and vehicles on their own, using the same pass/fail criteria and equipment that the NHTSA uses to ensure our vehicles are safe to drive.

Seeing an entire industry become so involved in the standards development and conformity process like this is really gratifying. It makes me feel good about what I do, and we have better products on the market today because of it.

With a solid foundation in place, we turned our attention to the inside of the compartment. We took many of the issues the community identified during research and approached them with “human factors” in mind. Human factors are concerned with understanding how humans interact with their surrounding system—in this case how EMS providers interact with their patients and the workspace in the patient compartment. Based on the information collected, we developed more than 200 individual criteria that focus on improving seating and restraints, workspace, communications, storage, and other areas.

With a team of computer scientists, systems engineers, human factors experts, and a DHS contractor, we developed several new designs for patient compartments. Then we loaded the designs into simulation software so we could apply different emergency scenarios (e.g., cardiac arrest, trauma) and see if a provider could do everything he needed to do to provide care while remaining seated and restrained.


An animation of our ambulance design. Click image to play. Credit: NIST/BMT Designers and Planners

After we finished with that, we worked with NFPA and CAAS to make sure that they were incorporating human factors into their standards—things like how best to position the cot, equipment, cabinets, and needle disposal so that they were all within arms-reach of the EMS provider. They are defining what is “in arms-reach” in terms of where the majority of care will take place, the primary patient care position—where the EMS provider sits.

We also pushed for recessed overhead lighting, handle bar requirements, and clearance space around the provider’s head to limit the chances for severe head trauma. And lastly, as a complement to the standards, we worked with DHS and its contractor to develop the Ambulance Patient Compartment Human Factors Design Guidebook, which serves as a starting point for the design of new ambulances and contains best practices for human factors, lighting, climate control, and communication.

Ambulances save lives every day, but too many lives are lost when ambulances get into accidents. Our NO. 1 goal with this project was to keep EMS providers seated and restrained so that they can work to save their patients’ lives without having to risk their own.

I’m proud of what we've accomplished. I have no doubt that these standards will keep both our brave EMS providers and their patients safer in the future.

First published May 9, 2016, on NIST’s Taking Measure blog.

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About The Author

Jennifer Marshall’s picture

Jennifer Marshall

Jennifer Marshall is a physical scientist within the Standards Coordination Office (SCO) at the National Institute of Standards and Technology (NIST). Marshall has nearly 15 years’ experience in technology and standards development for emergency medical services, fire service, law enforcement, and the larger homeland security community. Prior to NIST, Marshall developed multiyear research, test, and evaluation plans for programs that supported Federal, state and local public safety community. At the Department of Energy’s Environmental Management Office she sought alternative decontamination technologies for our national nuclear waste facilities.