Addressing Ambulance Standards

The safety and design standards for ambulances in the U.S. will soon be changing, but while the new requirements are supposed to be in place by 2016, the industry has yet to reach consensus on just what those standards will look like. This poses an interesting problem for ambulance manufacturers, which will need to abide by the new standards, and the Office of EMS in each individual state, which will need to adopt one of two competing sets of requirements.

Since 1974, the KKK-A-1822 (A-F) purchasing specification—or “Triple K”—has served as the guideline by which federal agencies and grant recipients purchase ambulances. However, while a majority of states use the Triple K specs, ambulance manufacturers and their customers have raised concerns in recent years about the need for safety requirements that just aren’t addressed in the guidelines. As a result, the Triple K standards are set to sunset at the end of this year and the EMS industry will need to adopt new guidelines beginning in 2016.

What’s slowing that process down, however, are competing sets of standards on the table. Both the Commission on Accreditation of Ambulance Services (CAAS) and the National Fire Protection Association (NFPA) have proposed new ambulance guidelines, and each set of standards differs.

The NFPA’s standard, the NFPA 1917, is based on the organization’s standards for fire apparatus. According to the NFPA, it was developed with consideration of the Federal Specification KKK-A-1822 and NFPA 1901: Standard for Automotive Fire Apparatus. NFPA 1917 defines the minimum requirements for the design, performance and testing of new automotive ambulances intended for use under emergency conditions to provide medical treatment and transportation of sick or injured people to appropriate medical facilities.

NFPA states the standard presents general requirements for ambulance design and performance, along with standalone chapters for ambulance components, including chassis, patient compartment, low-voltage electrical systems and warning devices, and line voltage electrical systems. NFPA 1917 also specifies provisions for test methods.

Published in 2012, NFPA 1917 immediately met with resistance from the EMS industry, which noted a number of requirements viewed as overly restrictive, including limits on design and speed.

In response, CAAS, a not-for-profit ambulance accreditation organization, came out with its own set of standards, the CAAS Ground Vehicle Standard (GVS-2015). Developed by a coalition of industry groups from EMS and the fire service, the CAAS guidelines identify the minimum requirements for new EMS ground ambulances built on OEM chassis and prepared for use as an ambulance. This standard applies to new vehicles only and does not include:

• Military vehicles/combat support ambulances
• Wheel chair vans/transport vehicles
• Mass-casualty vehicles/ambulance buses
• Refurbished or remounted ambulances
• Fire apparatus

According to CAAS, the purpose of the CAAS GVS-2015 is to “best serve patients by providing ground ambulances that are safe, nationally recognized, properly constructed, easily maintained, and when professionally staffed and provisioned, will function reliably in prehospital or other mobile emergency medical service.”

Right now, there’s no easy resolution in sight. Both the NFPA and CAAS have planned revisions to their standards during 2015, and as of now neither plan seems to have gained a foothold across the entire EMS industry.

But if one plan does gain universal acceptance, it’s going to dramatically affect the way ambulances are designed for years to come. Right now ambulance manufacturers can design and build to any standard. But if there’s just one accepted standard going forward, it’s going to make it easier and more cost effective for manufacturers to build vehicles. And it very likely could mean new safety features on ambulances that better protect the lives of patients and providers.

Comparing Ambulance Standards

How does each ambulance standard—the Triple K, CAAS and NFPA—compare when looking at the requirements addressed across all three? Below is a chart comparing 30 requirements noted in each standard. Of particular note are the number of similarities between the new CAAS GVS-2015 standards and the old Triple K.

Society of Automotive Engineers Release Crash Safety Standards

When industry experts gathered in Nashville for EMS World Expo 2014 (see video at www.emsworld.com/12030641), among the topics of discussion was building ambulances to meet new crash safety requirements from the Society of Automotive Engineers (SAE). Those requirements, released in July 2014, are aimed at creating safer patient compartments and work environments for EMS personnel.

That's important because ambulance crashes aren’t an insignificant problem. Between 1992–2011 there were an annual estimated mean of 4,500 motor vehicle traffic crashes involving an ambulance.

Of these crashes:

• 65% resulted in property damage (only)
• 34% resulted in an injury/injuries*
• <1% resulted in a fatality/fatalities*

*Injuries and fatalities include occupants in all cars involved in a traffic crash involving an ambulance

Additionally, during this 20 year period there was a mean of 29 fatal ambulance crashes and 33 fatalities (includes occupants and non-occupants of all vehicles involved) each year. And there were an estimated annual mean of 1,500 injury crashes involving an ambulance and 2,600 injured persons (includes ambulance occupants and occupants of all other vehicles involved).

Of the annual mean 29 fatal crashes involving an ambulance, 58% occurred while the ambulance was in emergency use, while 42% occurred while in non-emergency use. Of the estimated annual mean 1,500 injury crashes, 59% occurred while the ambulance was in emergency use, and 34% occurred while in non-emergency use.

According to Jim Green, project officer, Division of Safety Research, National Institute for Occupational Safety and Health (NIOSH), the overarching goals of the effort to revise the ambulance crash safety standards were to:

• Provide patient compartment occupants with the same level of crash protection as passenger vehicles;
• Work with end users to ensure designs meet needs;
• Develop system specific standards for publication to be referenced nationally or internationally in the near term;
• Incorporate changes into one or more bumper-to-bumper ambulance national standards in the long term; and
• Most importantly, ensure all proposed standards are based on actual test data.

Among the new requirements is the J3027 recommended practice that describes testing procedures for evaluating the integrity of ground ambulance patient litters, litter-retention systems and patient restraints in frontal and side-impact collisions. Its purpose, the SAE says, is to provide litter manufacturers, ambulance builders and users with testing procedures and acceptance criteria to ensure the patient litter, its retention system and the patient restraint utilize dynamic performance test methodologies similar to those applied to other vehicle seating and occupant restraint systems. It includes descriptions of the test setup, instrumentation, photographic/video coverage, test fixtures and performance metrics.

Released at the same time as J3027, J3043 explains dynamic and static testing procedures for evaluating the integrity of equipment-mount devices or systems in a frontal or side crash. It is intended to provide equipment manufacturers, ambulance builders and users with testing procedures and acceptance criteria to ensure mounting mechanisms meet the same performance criteria across the industry. It allows manufacturers to conduct either dynamic testing or static testing.

A third recommendation, J3026, specifies testing procedures to evaluate the integrity of ground ambulance occupant seating and restraint systems for workers and civilians transported in the patient compartment during frontal and side collisions. This practice is based on specific dynamics of the ambulance patient compartment and doesn’t apply to other vehicle applications or seating positions. J3026 accommodates seating systems installed in multiple attitudes, including side-facing, rear-facing and forward-facing. Its purpose is to ensure ambulance occupant seating and restraint systems meet similar performance criteria as FMVSS 208 requires for seat-belted passengers in light vehicles.

Additional work on these standards remains underway, Green said. This includes:

• SAE J3057: Patient compartment structural integrity standard, which will dynamically and statically test the modular body to improve a builder’s ability to design and test for roll impact loading. Likely to be published in summer 2015;
• SAE J3058: Cabinet and cabinet latch integrity standard, which will ensure cabinets retain equipment using established crash pulses. Likely to be published in summer 2015;
• Interior surface delethalization involves making impact surfaces less likely to injure the worker or patient; and
• EMS Worker Anthropometry Study, which will assess body sizes and shapes (620 human subjects planned—480 completed so far).

References
CAAS. Ground Vehicle Standard (GVS-2015), www.groundvehiclestandard.org.

NASEMSO. Differences Between NFPA 1917 (8/29/12), KKK-F and ASTM, www.nasemso.org/Projects/AgencyAndVehicleLicensure/documents/NFPAfinalcondensedcomparisons11-12.pdf.

NFPA. NFPA 1917: Standard for Automotive Ambulances, www.nfpa.org/codes-and-standards/document-information-pages?mode=code&code=1917.