St Outline Advances In Critical Care Transport, Akron .
1st Neonatal/Pediatric Transport Conference,Ambulance Transport Safety:Where is the State of the ArtMoving Sick Kids Safely - OptimizingTransport Safety for Crew, Neonates, andChildrenOutlineWelcomeAdvances in Critical Care Transport, Akron, Ohio 2006fCincinnati Children’sfAngel One – Arkansas Children’s HospitalfCarolinas Medical CenterfChildren’s Hospital Columbus OhiofChildren’s National Medical CenterfAkron Children’s HospitalI.II.III.IV.V.Nadine Levick, MD MPHDirector, Division Emergency Medicine ResearchMaimonides Medical Center, New YorkLook at the data on ambulance transportsafetyHighlight important predictable andpreventable occupant risks and hazardsduring neonatal and pediatric transportDemonstrate what happens during anambulance crashReview of guidelines, standards andinnovationOutline practices and strategies toenhance occupant safety and reducerisks of crash-related injuryKey Issuesf Mythology That Emergency Medical Service personnel are safef Injury Hazards Biohazard Chemical/Radiation Physical/Mechanical trauma – THE BIG PROBLEMf Motor Vehicle Crashes are the highest cause of deathat work – EMS has 2X the mean national ratef An R & D and Regulatory Gap Occupational Health and Safety the workplace is in a vehicle – exposure data are scant Automotive Safety a vehicle is the work place – ‘exempt’ from automotive researchand regulationSafety oversight of what and by .whomfVehicle SafetyfVehicle DesignfSafety Equipment DesignfVehicle and Safety EquipmentTesting and Standard developmentfSafety policiesPediatric Patient Transport SafetyIS Complex AND MultidisciplinaryEpidemiologicalData CollectionRiskManagementTransportPractice Epidemiology, Bio/Chem Hazards and Ergonomics Regulation and ResearchfAutomotive tyIdeally Who, What and Where ?fOccupational Health and SafetyTransportSafetyTransportPolicyPPE Epidemiology, Engineering and Impact Biomechanics Regulation and ResearchfEMS Industry Occ. Health, Automotive, Technical, Clinical & Fiscaldata Practice Policy, Risk Management and Fleet SafetyBiohazard/ChemResearchPublicSafetyFleet SafetyProgramRegulationsand StandardsfAcademia Independent and collaborative R & D and evaluation of all of the above
GoalsThe NTSBf Standards for safetyf Policy based on Sciencef Databases to demonstrate outcomeSafety in PediatricAmbulance TransportfIs part of a SYSTEMhttp://www.objectivesafety.netthe Peds atchTpolicies and proceduresthe pediatric patientIrestraining device/seatMtransporting device/gurneyEparamedics/transport nurses, doctors & familypatient monitoring equipment&clinical care & interventionsthe vehiclePLACEthe driver/driving skillthe roadFirstly!fAn accident ?fora predictable and preventableevent“Are our policies killing people?”f1991-2000, 302,969 Emergency vehicles wereinvolved in MVCs - 1,565 involving fatalities*fIn PA 1997-2001, ambulances were more likelythan similar sized vehicles to be involved in*: 4 way intersection crashes (43% vs 23%, p 0.001) Collisions at traffic signals (37% vs 18%, p 0.001) MVCs with more people injured (76% vs 61%, p 0.001)*Comparison of Crashes Involving Ambulances with those of similarsized vehicles – Adam Ray, Douglas Kupas, PEC Dec 2005;9:412-415
So. The real world for an EMSvehicle approaching a red lightVision Zero:An ethical approach to safety and mobilityfYou think they heard you fYou know they must have seen you.fAnd maybe they didf . But.fThere is NO way humanly possiblethat they could stop .Is there an acceptable rateof morbidity and mortalityfor pre-hospital transportsystems?This is not acceptable911 Call to Hospital/ED Definitive CareTime Intervals*f One fatality each week# 2/3 pedestrians or occupants of other car 4 child fatalities per year ( 2X airbags patchedEMSarriveson sceneEMSleavessceneEMS arrives Hospital/EDat ED EMSdefinitivebaycareEMSEMS scene EMS scene to ED EMS bay toresponse tohospital/EDhospitaltimethe scenedefinitive caretransporttimetime (Y)time (X)Vehicle related transport time*Not drawn to scale*Kahn CA, Pirrallo RG, Kuhn EM, Prehosp Emerg Care 2001 Jul-Sep;5(3):261-9**Becker, Zaloshnja, Levick, Li, Miller, Acc Anal Prev 2003***Maguire, Hunting, Smith, Levick, Annals Emerg Med Dec 2002#NIOSH, 2003##Ray AM, Kupas DF, Prehosp Emerg Care 2005 Dec; 9:412-415##NHTSA, 49 CFR Parts 571, 572 & 589 Docket no. 92-28; notice 7Dan BerryTransport Canada, Ministry of HealthengineeringBest,Zivkovic,RyanTurbell etal,SwedenWe should use the best safetypractices demonstrated1960‘70nonissueLevick Levick Levick Levick Levick Levicket alet alet alet alet alet alBull,Taltyet al‘78EMSC PED-SAFE-TLevick et alLevicket alHighnettet alDe Graeve,Deroo, CalleCalle, Weiss, Maguire, et alBecker,Biggers, et al et alHunting, MMWR Zaloshnja,Pirrallo, Zachariah,Kahn, Smith, NIOSH, Levick, Li, RaySworPepePirrallo Levick CDCMillerKupasSaunders et alFEMANTSB/ AuerbachEVOC et alEMSdispatchtime*FARS/BTS 2004Predictable risksAmbulance Safety Research:A New Fieldepidemiology NHTSA/fCost estimates 500 million annuallyf More often at intersections, & with another vehicle (p 0.001)*f Most serious & fatal injuries occurred in rear (OR 2.7 vsfront) & to improperly restrained occupants (OR 2.5 vsrestrained)*f 82% of fatally injured EMS rear occupants unrestrained**f 74% of EMT occupational fatalities are MVC related***f Serious head injury in 65% of fatal occupant injuries#f 70% of fatal crashes EMS crashes during Emergency Use#f More likely to crash at an intersection with traffic lights(37% vs 18% p 0.001) & more people & injuries/crash thansimilar sized vehicles##Vision Zero is a philosophy of road safety that eventuallyno one will be killed or seriously injured within the roadtransport system. Vision Zero describes the view thatsafety cannot be traded for mobility. Sweden’s Vision Zerois aimed at eliminating all deaths or long-term healthlosses arising from road crashes. The mobility in the roadtransport system should be a function of the safety andnot vice versa”.ergonomicf 10 serious injuries each dayfUSA Crash fatality rate/capita 35x higherthan in Australia- Claes Tingvall‘86‘93 ‘95 ‘96 ‘98 2001 ‘02 ‘03 ‘04 ‘05? safesaferWhat do we know now?fIntersection crashes are the most lethalfThere are documented hazards, some which canbe avoidedfOccupant and equipment restraint with standardbelts is effective. (Over the shoulder harnesses forpatients should be used, with the gurney in the uprightposition where medically feasible)fSome vehicle design features are beneficial automotive grade padding in head strike areas,seats that can slide toward the patientfElectronic Driver monitoring/feedback systemsappear to be highly effectivefHead protection?
Balance of concerns and riskduring transportHaddon/Baker/Runyan Phase-Factor MatrixFACTORPHASE(host)pre crash(pre event)f Response and transport timecrashf Clinical care provisionf Occupant safety/protection(event)post crash(post event)f Public SafetyConcernsf Consequences can be predictable & likely preventablef Costs of these adverse events are high in loss of life,financial burden and negative impact on delivery of EMScaref Much uncertainty as to what is safe and what is unsafeoccupant protection practicef Other high speed vehicles (eg. racing cars) have adifferent safety paradigmf Design of interventions to mitigate injury is predicated ona valid testing modelf Complex both engineering and public health issuesIdentifying predictable andpreventable transport relatedrisks and iered dispatch,driving history,collisionEVOCavoidance,driver education,implemented,speeding,anti lock brakes, road design,abiding roadvehicle weight,markingslawsspeed& surfaceseat belt, restraintair bagsuse,restraint designchild safety bumper & crumpleseat usezone designgender,severity, age,underlyingmorbidityease ofextrication, burnresistant fabricsSociocultural(physical/regulatory)collision speed,road sidehardwareEMSsystem,qualitytrauma care,trafficmanagementsystemEMS image(scoop & run),public/paramedicawareness,disorientationfrom L & Sit canand doeshappen Effectiveness Cost benefit Ethics Socialacceptability Societal needrehabilitation,documentationand datacollectionWhat are the risks? Lack of tiered dispatch systemsFrequent use of high speedIssues of adherence to road lawsHigh use of L & S.Rear cabin Communications Personnel Transport Equipment Environmentf ? total no. of ambulancesf ? total no. of medicsf ? total no. of runs (per age & severity)f ? total pt. miles (per age & severity)f ? true crash fatality rate per milef ? crash injury ratef ? adverse eventsUSA Ambulances:FMVSS Exempt not subject to any automotive safety regulation minimal structural crashworthiness features inadequate and poorly studied occupant and equipment restraintutilization and safety The only design standards that are written specificallyfor ambulance vehicles (KKK specs) are purchasespecifications, not performance specificationsMultidisciplinary collaborationand the way forwardfDevelopment of interdisciplinary teamsfSystems approachEMS Research /Data Vacuum healthcare professionalssafety engineering expertiseregulatory bodiesmanufacturersfSafer practices save lives, time and moneyProtective devices/conceptsIn the event of a crashf Vehicle crashworthinessf Seat/seat belt systemsf Equipment lock downsf Paddingf Head protectionTo prevent a crashf Driver feedbackf Driver monitoringf Driver trainingf Vehicle and other technologiesf Tiered dispatchf Appropriate policies
This is happening out thereNOW .Gregg Theunes Appeal to hisSenator, December 29, 2005This is where automotive safetyis happening –where is EMS?Enhanced Safety of Vehicles (ESV) – TheDefinitive Vehicle Safety ForumAmbulance vehicle safety has only been presented at oneESV meeting, the 17th ESV in 2001Crash Occupant Protectionf collision speedSafety for emergencytransportf direction of impactf EMS Safety and Performance Standardsf vehicle stiffness and massf compartment size & projectilesf intelligent vehicle technologyf passive protectionPolicy that reflectsSCIENCEf head protection Australia & New Zealand 4535 Common European Community (CEN) EN1789 (International Joint Commission on Medical Transport)f Non EMS Specific USA Standards [Aviation - FAA/CAA/JAA] [New ASSE/ANSI Z15 – fleet vehicles]f USA Otherf occupant restraint/beltsAmerican National StandardSafe Practices for Motor Vehicle Fleet OperationsNew ANSI/ASSE Z15.1-2006Global EMS Vehicle SafetyStandardsv Specifications and Guidelines Purchase Specification: KKK & NTEA – AMD Guideline: EMSC Dos and Donts, and (CAAS and CAMTS)Transport Safety GuidelinesEMSC/NHTSA fact sheetDo’sDon’tsb DO drive cautiously at safe speeds observingtraffic laws.r DO NOT drive at unsafe high speeds with rapidacceleration, decelerations, and turns.b DO tightly secure all monitoring devices and otherequipmentrDO NOT leave monitoring devices and otherequipment unsecured in moving EMS vehicles.b DO ensure available restraint systems are used by rDO NOT allow parents, caregivers, EMTs orEMTs and other occupants, including the patient.other passengers to be unrestrained duringtransport.b DO transport children who are not patients,rDO NOT have the child/infant held in the parent,properly restrained, in an alternate passengervehicle, whenever possible.caregiver, or EMT’s arms or lap during transport.b DO encourage utilization of the DOT NHTSAEmergency Vehicle Operating Course (EVOC),National Standard //www.nhtsa.dot.govhttp://www.nhtsa.dot.govr DO NOT allow emergency vehicles to be operatedby persons who have not completed the DOT EVOCor equivalent.Benefit of SafetyfAny cost of addressing these issuesis dwarfed in contrast to the hugeburden of not doing so - in financialcosts let alone the personal, societal,ethical and litigation costs
Cost ?fLoss of life and serious injury to EMSproviders, patients, publicfInsurance payouts per serious crash 10- 35 millionfEstimated in excess of 500 millionannuallyThis is about you and yoursafetyRisk to who?fHealth care interventionsthat are a risk to: Patients (their families?) Providers PublicUSA EMS Risk/HazardsfPredictable risksfSerious occupational hazardfPredictable fatal injuriesAir EMS is a role model forsafety initiatives and focusfWhat safety practices do you use? Seat belts ? EVOC training ? Equipment lock down ? Helmets ? “Black Box” technology ? Tiered dispatch ?head protection?It does happen .Key Helmet Features
Creating a Safety Culturewithin a company must start with uppermanagement’s commitment to safetyIdentifying predictable andpreventable transport relatedrisks and hazardsfSystems approachfAwarenessfTrainingfIncentive Communications Personnel Transport Equipment EnvironmentDynamic Safety Testingf requires sophisticated, expensiveequipmentf measurably demonstrates forcesgenerated during collisionf accepted international standardfor vehicle restraint systemsTest 1 – Right side impact12New concepts out there nowfBlack BoxesfTiered dispatchfHelmetsfEnhanced ambulance vehicle designfIntelligent Transport Technologies - ITSfNew Safety Standards1 – Target vehicle,Type I ambulanceTest 2- Frontal2 – Bullet vehicle,Type II ambulanceJohns Hopkins University2Closing speed 44 mph1 – Bullet vehicle,Type III ambulance2 – Target vehicle,Type II ambulance1Closing speed 34 mphJohns Hopkins UniversityThe “Black Box”Driver behavior monitoring and feedback deviceSo .fWhich vehicle do you want to be in ?fWhich vehicle is the best forefficient, and effective patient care?fWhich vehicle provides optimal riskmanagement ?fWhat is the optimal fleet mix?Important Principles !1. Ambulances are NOTstandard passenger vehicles
Important Principles !Important Principles !2. Pediatric patients inambulances have needswhich differ from children inpassenger cars3. Design, performance andpractice policy should bebased on properly conductedscienceA culture of safetyDrive cautiouslyWear your belts & restrain all occupantsSecure all equipment5. Integrate scientific data into yourpolicies and procedures- Unrestrained occupants and equipmentare a potential injury risk to all occupantsFuture Goals New vehicles New technologies Futuristic vehicles New policies New practices New StandardsAmbulance transport safety ispart of a SYSTEM, the overallbalance of risk involves thesafety of all occupants andthe publicFuture DirectionsVery Important Principles !1.2.3.4.Very Important PrinciplePREDICTABLEPREVENTABLEandNO ‘ACCIDENT’ConclusionfMajor advances in EMS transport safetyresearch, infrastructure and practice over thepast 5 yearsfEMS is still way behind the state of the art invehicle safety and occupant protectionfEnhanced cross disciplinary collaboration indevelopment of safety initiatives now existfFocus on safety of ALL aspects of theambulance environment - safer patient transportpractices exist & should be usedfNew safety developments are underway: beready to integrate them into your practicefAnd above all WE NEED DATAfRational use of limited resourcefAvoid reinventing the wheelfFormal safety research agendafFramework bridging key research andinfrastructure Society of Automotive Engineers Involvement with ESV activities EMS safety research funding Foster evidence based initiativesAnd .fIt is no longer acceptable for patienttransport to be functioning outside ofautomotive safety and PPE safetystandards for prevention of andprotection of EMS providers and thepublic from death or injury
Electronic Info:www.objectivesafety.netfElectronic Handout of today’s presentationf“Ambulance Safety: Where is the State of the Art?”Webinar June 14, 2005Recorded online - Free access via the internetfComprehensive Reference List on EMS SafetyAcknowledgementsffffffEMSC funding –Targeted Issues Grant, PED-SAFE-TThe late Capt. Garry Criddle – ExNHTSA/EMSCGeorge Gillespie & Michael Schultze – US Military NAWCJoe McIntire & Joe Liscina - USAARLAllan Blatt & Bruce Donnelly – Veridian/CalspanSteve Haracznak & Kurt Krumperman – AmbulanceAssociation of Americaf The USA EMS communityf Bill Murphy - Ontario Ministry of Healthf Muttiah Jeyendra - Standards Australiaf Research assistants – Allison Better, Tony Tsai, PhilipLee and Puneet Gupta.
***Maguire, Hunting, Smith, Levick, Annals Emerg Med Dec 2002 #NIOSH, 2003 ##Ray AM, Kupas DF, Prehosp Emerg Care 2005 Dec; 9:412-415 ##NHTSA, 49 CFR Parts 571, 572 & 589 Docket no. 92-28; notice 7 We should use the best safety practices demonstrated What d
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