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March 30, 2016

SAE Standards for ambulance safety

In 2014, the Society of Automotive Engineers released a set of four updated recommendations regarding safety standards for ambulances. The SAE is a professional organization that primarily develops "best practices" for the automotive, aerospace, and commercial vehicle industries. The four new recommendations join two existing sets of standards, and cover patient compartment restraint, litter integrity, equipment mounting systems, and both front- and side-impact safety systems.

The guidelines for ambulance safety were developed in conjunction with NIOSH and the Ambulance Manufacturers Division of the National Truck Equipment Association. Although a U.S. based group, the SAE recommendations are meant to be used globally in the development and production of ambulances and equipment.

Who determines ambulance design specifications?
The process of regulating ambulance safety varies significantly state by state. In the United States, the federal government outlines a set of specifications in a General Service Administration document called the KKK-A1822 (often referred to as "the Triple-K"). This set of specifications, developed in 1976, has gone through several updates, most of which were influenced by the evolving SAE recommendations [1].

In addition to the Triple-K, the National Fire Protection Association has also published its own ambulance design standards, called NFPA 1917. Like the Triple-K, NFPA 1917 incorporates many of the SAE recommendations for crash safety.

Finally, the Commission on Accreditation of Ambulance Services (CAAS) has a separate set of standards called GVS v1.0 that, like the Triple-K and the NFPA, is based on the SAE safety recommendations.

Although these three documents vary slightly in scope, they all set forth a number of best practices regarding ambulance design that agree with many of the current SAE recommendations. However, the adoption of any standard at all is not federally mandated.

Currently, 30 states use all or part of the Triple-K in their ambulance safety standards. Six states have no legislated ambulance design regulations at all, and the remaining states have regulations that may or may not include Triple-K or SAE specifications [2].

Although the Triple-K standards appear to be the most widely used, they are set to expire in October 2016, leaving the NFPA and CAAS standards in relative competition for adoption as the industry standard in EMS [3]. EMS leaders should research what standards, if any, are mandated in the state in which they operate.

Although state regulations play a major role in the adoption and implementation of any ambulance safety standards, other factors come into play. For example, any agency that receives equipment funding through the Assistance to Firefighters Grant is required, through the terms of the grant, to comply with published SAE standards regardless of any state regulations [4].

Individual equipment manufacturers, in an effort to be competitive and at the top of the market, design and sell products that meet many, if not all, of the SAE standards. Because of this, states without any regulation at all may still meet some or all of the suggested safety standards simply by nature of the equipment used in the ambulances operating within the state.

The actual SAE recommendations 
The bulk of the SAE recommendations describe specific testing standards to be used by equipment manufacturers to ensure the safety of patients and providers during ambulance operations. These tests strongly resemble those used by civilian auto manufacturers. In fact, a main point of the 2014 SAE recommendations is to provide patient compartment occupants with the same level of crash protection as passenger vehicles.

These standards include impact testing utilizing crash-test manikins positioned in front, side and rear facing ambulance seats, as well as secured to a gurney using the recommended combination of lap and shoulder belts. The SAE outlines both static and dynamic testing procedures with the goal of providing manufacturers with clear standards for evaluating the safety of their products. The recommended testing also includes equipment restraint systems, and systems used to secure the gurney in the patient compartment.

Traditionally, patient cots were secured in the patient compartment with a standard antler and rail system that stabilizes the head of the cot with floor-mounted metal antlers, and locks the foot of the cot into a side mounted rail. Patients are typically secured to the cot using a combination of lap and shoulder belts designed, in theory, to prevent forward movement of the patient during a collision.

A NIOSH study conducted during the development of the SAE standards showed that during a front-impact collision at a speed of 30 mph, the antler and rail system allowed for approximately 30 inches of forward movement of the patient cot and patient. The force of a front impact at 30 mph was significant enough to cause the gurney to break free of the antlers, sending a restrained patient forward into the space often occupied by the captain's chair or jump seat in the patient compartment [5].

The 2014 SAE standard J3027 requires that the patient cot be configured in such a fashion that forward movement of the cot and patient during a front-end collision is limited to 14 inches, rather than the previous 30 inches [6]. In July of 2015, the GSA adopted Change Notice 8, which added this requirement for cot and patient security (SAE J3027) into the KKK standard. This means that traditional antler and rail systems will no longer be compliant, should states adopt this aspect of the KKK standard.

The additional SAE standards also cover equipment-mounting systems and provide requirements for interior surface delethalization, making impact surfaces less likely to injure the patient or health care provider in the event of a collision. Equipment mounting systems in SAE compliant ambulances would need to show stability of standard equipment like oxygen cylinders and cardiac monitors during front, side, and rollover collision conditions.

Surface delethalization also involves replacing current hard impact surfaces with padded materials, or materials that collapse upon significant impact, in order to reduce injuries to providers during collisions.

Research and development continues in the area of provider restraint in the patient compartment. Identifying and implementing an effective provider restraint system is a challenging task, as the restraint must simultaneously allow movement during patient care while providing security in the event of a collision.

A variety of provider restraint systems exist, from bench seats that slide and swivel to retractable harness restraints that allow full movement around the patient compartment. While the SAE does not currently specify a specific restraint system, it does provide recommendations for the maximum allowable movement of a restrained provider in the patient compartment during an ambulance collision.

Another interesting inclusion in the SAE standards is an evaluation of provider body size and shape. The NIOSH EMS Anthropometry Study evaluated 680 human subjects in an attempt to identify common body sizes and shapes so that ergonomically efficient standards could be developed for ambulance construction and restraint systems [7].

This project is set to end in 2016, and will likely affect ongoing updates to the SAE standards. It is worth noting that the Triple-K, NFPA, and CAAS standards are all based on a provider weight of between 171 and 175 pounds, which may not accurately reflect the average provider size [3].

Improve safety habits
It is widely recognized that ambulance crashes are a significant problem. Between 1992 and 2011, an estimated 4,500 vehicle crashes involving an ambulance occurred each year. Of those, 34 percent involved injuries, and an average of 29 fatal crashes occurred each year [8].

The 2014 SAE standards, if adopted, will take years to fully implement as existing apparatus and equipment are replaced with new, compliant products. Until such time as ambulances become compliant with the new standards, providers should continue to practice safe habits when driving or working in an ambulance.

During patient care and transport, providers should be restrained by lap-shoulder belts when in front and rear facing seats, and lap belts when in side facing seats. Any additional restraint systems installed in an individual ambulance, such as five point harnesses, should be utilized whenever possible.

Patients should be secured to the patient cot with all available straps. Providers should be familiar with the manufacturer recommendations regarding proper fit of patient cot straps or seatbelts to ensure the patient is as protected as well as possible in the event of a collision.

Given the propensity of antler-rail mounted gurneys to move significantly forward during a collision, providers should avoid sitting directly behind the head of the patient cot whenever possible.

Heavy bags and equipment should be routinely secured during ambulance operations. Oxygen cylinders, cardiac monitors, and larger suction units should all be firmly stabilized to prevent movement during a collision or rollover. Loose equipment unsecured in the patient compartment, even small items, should be avoided. Cabinets and bins should either be securely closed or the items inside them otherwise confined to the inside of the cabinet space.

Finally, there is no substitute for careful, aware, defensive driving when it comes to maximizing the safety of patients and providers, as well as the drivers and occupants of other vehicles. An Emergency Vehicle Operation Course provides necessary training in safe ambulance driving.

It is critical to avoid distractions while driving such as eating, drinking, radio usage, GPS navigation and smartphone communication. Communication between the driver and the provider in the patient compartment regarding bumps, sharp turns, and other road conditions is of high importance.

It remains the individual responsibility of each provider to always use seatbelts and restraints in the manner in which they were intended, to minimize the potential for injury in the event of a collision. As with any other aspect of EMS work, personal safety for the provider must be the first priority during ambulance operations.

References:

1. Vogt F (1976). "Equipment: Federal Specification, Ambulance KKK-A-1822". Emerg Med Serv 5 (3): 58, 60–4. PMID 1028572.

2. "Executive Summary, Understanding the SAE Conversation." Executive Summary. Ferno. Web. 13 Mar. 2016.

3. "AEV Briefing on Current Status of Ambulance Standards Projects." NAEMT.org. Web. 13 Mar. 2016.

4. "Assistance Firefighter Grant." Fema.gov. Web. 13 Mar. 2016.

5. Castillo, Dawn, Thomas Bobick, and Stephanie Pratt. "New Research and Findings from the NIOSH Division of Safety Research." ASSE Professional Development Conference and Exposition. American Society of Safety Engineers, 2013.

6. "Ambulance Patient Compartment Seating Integrity and Occupant Restraint." J3026. Web. 13 Mar. 2016.

7. "EMERGENCY MEDICAL SERVICES WORKERS." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 2014. Web. 13 Mar. 2016.

8. "NHTSA Traffic Safety Facts 2011." National Highway Traffic Safety Administration. NHTSA.gov. Web. 13 Mar. 2016

9. "About SAE International." SAE Mission and Vision Statements. Web. 15 Mar. 2016.

About the Author

Shawna Renga, AS, NREMT-P, currently teaches at the University of San Francisco Emergency Medical Technician Program in San Francisco, CA. Previously she worked as the Assistant Program Director for the EMT program at the San Francisco Paramedic Association. Shawna also works as a paramedic for a private ambulance service in Marin County California.
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