1. THOMCO EMS SAFETY NET SEMINAR, 2007

2. Relative Risk of Injury and Death in Ambulances and Other Emergency Vehicles Les R. Becker, Ph.D., NREMT-P Associate Research Scientist Public Services Research Institute Pacific Institute for Research & Evaluation Calverton MD 20705

3. THOMCO EMS SAFETY NET SEMINAR, 2007 Acknowledgements This research was supported by US Health Resources and Services Administration Emergency Medical Services to Children Grant No. 1 H15 MC00069 to the Johns Hopkins University and Grant Number 5 RO1 OH03750-02 to the Pacific Institute for Research and Evaluation.

4. THOMCO EMS SAFETY NET SEMINAR, 2007 Introduction EMS response is a fundamental feature of EMS systems (Boyd et al., 1983). Ambulance crash studies have lagged behind the growth of EMS in the U.S. The first examinations of ambulance crashes began in the early 90’s.

5. THOMCO EMS SAFETY NET SEMINAR, 2007 Overview Review of Early Studies Review of the PIRE Study Review of EMS Seat Belt Use Discussion of Prevention Approaches Proposal of a New Approach

6. THOMCO EMS SAFETY NET SEMINAR, 2007 Earlier Studies Auerbach (1987) studies a very small sample of Tennessee ambulance crashes: –Approximately 50% of vehicle-drivers and front-seat occupants were wearing occupant restraints; –Over one-half of prone stretcher patients were restrained; –15% of bench seat and 100% of jump seat patients were wearing restraints.

7. THOMCO EMS SAFETY NET SEMINAR, 2007 “ We conclude that passenger restraints for both ambulance attendants and passengers should be mandatory and we suggest that traffic signals be strictly heeded at intersections and speed limits in urban settings be obeyed.” Auerbach et al., 1987

8. THOMCO EMS SAFETY NET SEMINAR, 2007 Earlier Studies Larmon et al. (1993) reported that 67.9% of 900 EMTs surveyed identified inhibition of patient care as a reason for non-use in the patient compartment.

9. THOMCO EMS SAFETY NET SEMINAR, 2007 Earlier Studies Saunders and Heye (1993) –San Francisco Public Health Department ambulance crashes; –Over 27 months; LocaleVehicle TypeCollisions per 100- million miles traveled All CA.All 213.2 SFAmbulances 13,333

10. THOMCO EMS SAFETY NET SEMINAR, 2007 Earlier Studies Four percent of 439 emergency medical technicians responding to a survey in New England reported that they had been involved in a crash (Schwartz et al. 1993) Sayeh et al. (1998) surveyed 2,672 EMTS in New England and Los Angeles. –37% in New England reported crash involvement; –26% in LA reported crash involvement.

11. THOMCO EMS SAFETY NET SEMINAR, 2007 Earlier Studies Pirrallo and Swor (1994) compared emergency and non-emergency ambulance crash fatalities. –Retrospective, cross-sectional, comparative analysis of 109 fatal crashes (126 deaths) from 1987-1990 using FARS data; –NY, MI, CA and NC accounted for 37% of all fatal crashes.

12. THOMCO EMS SAFETY NET SEMINAR, 2007 Earlier Studies Pirrallo and Swor (1994) [cont’d]: –69% occurred during emergency runs and 31% occurred during non- emergency runs; –Most emergency run fatal crashes occurred between 1200h and 1800h. –Most non-emergency fatal crashes occurred when lighting conditions were poor.

13. THOMCO EMS SAFETY NET SEMINAR, 2007 Earlier Studies Pirrallo and Swor (1994) [cont’d]: –No statistically significant differences between emergency and non-emergency crashes based: Day of week SeasonAtmos. Conditions Roadway Surface Type Roadway Alignment Relation to Junction Manner of Collision Year Manufact ured Vehicle Role Vehicle Maneuver Manner Leaving Scene Extent of Deformati on Violations Charged # of Fatalities Roadway Surface Condition Speed Limit

14. THOMCO EMS SAFETY NET SEMINAR, 2007 Earlier Studies Biggers et al. (1996) studied one year of ambulance crash data in Houston. –Driver history of a prior EMS vehicle crash was a key risk factor for future crashes. Drivers with a history of previous crashes were involved in 33% of all collisions. Five drivers accounted for 88.2% (15/17) of all injuries.

15. THOMCO EMS SAFETY NET SEMINAR, 2007 Earlier Studies Kahn et al. (2001) analyzed 1987-1997 FARS data and found that unrestrained rear occupants were most at risk for fatal and/or incapacitating injuries. –Most crashes occurred at intersections; –Dry, straight, improved roads; –On clear days; –Striking a second vehicle; –84% of the crashes involved fatalities; –78% of the fatalities were not ambulance occupants;

16. Our Work

17. THOMCO EMS SAFETY NET SEMINAR, 2007 Methods Merged 1988 through 1997 GES and FARS data; Police, ambulance vehicles and fire trucks; Modified KABCO scale –No injury; –Possible/non-incapacitating injury –Incapacity injury –Fatal injury

18. THOMCO EMS SAFETY NET SEMINAR, 2007 Methods Ordinal logistic regression rather than separate odds ratio calculations; Independent variables: –Vehicle type –Response Mode –Restraint Use –Seating position Dependent variable –Injury severity (KABCO score)

19. Results

20. THOMCO EMS SAFETY NET SEMINAR, 2007 Number of Crashes, 1988-1997 FatalNon-fatalTotal Ambulance30536,69336,998 Fire trucks16629,79029,956 Police Cars1,113183,371184,984

21. THOMCO EMS SAFETY NET SEMINAR, 2007 Number of Fatalities, 1988-1997 EVO’sOthersTotal Ambulance74286360 Fire trucks43152195 Police Cars2289711,199

22. THOMCO EMS SAFETY NET SEMINAR, 2007 Number of Non-Fatals,1988-1997 EVO’sOthersTotal Ambulance10,39812,54522,943 Fire Trucks3,6606,85110,511 Police Cars49,95045,44291,392

23. THOMCO EMS SAFETY NET SEMINAR, 2007 Injury Severity of Ambulance Occupants, 1988-1997 Fatal 71 (0.11) Incapacitating1,669 (2.70) Possible/ Non- incapacitating 7,796 (12.62) No Injury52,248 (84.57) Total61,784

24. THOMCO EMS SAFETY NET SEMINAR, 2007 Incapacitating Injuries By Response, Restraint Use & Seating Position EmergencyFrontR390 U13 BackR5 U531 RoutineFrontR313 U220 BackR0 U197 Total1,669

25. THOMCO EMS SAFETY NET SEMINAR, 2007 Fatal Injuries By Response, Restraint Use & Seating Position EmergencyFrontR4 U3 BackR6 U18 RoutineFrontR7 U6 BackR8 U19 Total71

26. THOMCO EMS SAFETY NET SEMINAR, 2007 Relative Risks

27. THOMCO EMS SAFETY NET SEMINAR, 2007 Summary of Findings Unrestrained ambulance occupants involved in a crash had nearly 4 times greater risk of fatality than did restrained ambulance occupants. Unrestrained ambulance occupants involved in a crash had nearly 6.5 times greater risk of suffering an incapacitating injury than did restrained ambulance occupants.

28. THOMCO EMS SAFETY NET SEMINAR, 2007 Summary of Findings The risk of a fatality versus no injury for ambulance rear occupants was over 5 times greater for ambulance rear occupants than for front-seat occupants if involved in a crash. Ambulance occupants traveling non- emergency were 2.7 times more likely than occupants traveling emergency to be killed if involved in a crash.

29. THOMCO EMS SAFETY NET SEMINAR, 2007 Summary of Findings Ambulance occupants traveling non- emergency were nearly 1.7 times more likely than occupants traveling emergency to suffer an incapacitating injury if involved in a crash.

30. THOMCO EMS SAFETY NET SEMINAR, 2007 Conclusions Clearly, occupant restraints are not used consistently in ambulances. Unrestrained ambulance occupants, occupants riding in the rear compartment and especially unrestrained occupants riding in the rear compartment are at substantially increased risk of injury and death when involved in a crash. One prior study suggests that occupant restraints are more commonly used for patients than for crew members.

31. THOMCO EMS SAFETY NET SEMINAR, 2007 Implications for EMS Safety Practices Ambulance occupants, including providers, should use safety restraints whenever feasible. Individuals accompanying patients during transport should ride in the front seat of the ambulance whenever feasible.

32. SEAT BELTS & PREVENTION

33. Prevention Fact!

34. THOMCO EMS SAFETY NET SEMINAR, 2007 “The use of safety belts is the single most effective means of reducing fatal and nonfatal injuries in motor vehicle crashes.” Dinh-Zarr, Sleet, Schultz et al., 2001

35. THOMCO EMS SAFETY NET SEMINAR, 2007 Seat Belt Use in the U.S.

36. THOMCO EMS SAFETY NET SEMINAR, 2007 Seat Belt Use in the U.S.

37. THOMCO EMS SAFETY NET SEMINAR, 2007 Seat Belt Use in the U.S.

38. What do we know about seat belt use in EMS?

39. THOMCO EMS SAFETY NET SEMINAR, 2007 Perceived Need for Freedom Cardiac Arrest82% Chest Pain or Dysrhythmia 63% Shortness of Breath 38% Trauma41% Cook et al., 1991

40. THOMCO EMS SAFETY NET SEMINAR, 2007 Seat Belt Use by Providers % Rarely Wearing Safety Belts (<5% use) % Always Wearing Safety Belts (>95% use) Routine front seat3.774.0 Emergency front seat 3.980.6 Routine back compartment 59.47.0 Emergency back compartment 77.43.2 Larmon et al., 1993

41. THOMCO EMS SAFETY NET SEMINAR, 2007 Prevention Approaches The ‘Three E’s’ –Education –Engineering –Enforcement

42. More Prevention Fact!

43. Single Approaches In Isolation are Rarely Effective!

44. THOMCO EMS SAFETY NET SEMINAR, 2007 Solutions? Education –EVOC –Driving Simulators Engineering –Speed regulators (“governors”) –“Black Box” Approaches –Harness Systems Enforcement –Organizational policies and sanctions

45. THOMCO EMS SAFETY NET SEMINAR, 2007 Solutions?

46. THOMCO EMS SAFETY NET SEMINAR, 2007 Effectiveness? At least one small-scale study –36 vehicles over 18 months –>250 drivers –Over 1.9 million miles, distance between penalty counts increased from baseline of 0.018 to high of 15.8 miles –Seatbelt violations from 13,500 to 4 The vendors of systems marketed today advocate effectiveness based on small-scale trials. NIOSH will be reporting preliminary findings from their harness studies at the upcoming NHTSA-sponsored Ground Ambulance Safety Roundtable.

47. THOMCO EMS SAFETY NET SEMINAR, 2007 Another Approach?

48. THOMCO EMS SAFETY NET SEMINAR, 2007 Provider Safety

49. THOMCO EMS SAFETY NET SEMINAR, 2007 Provider Safety

50. THOMCO EMS SAFETY NET SEMINAR, 2007 Patient Safety

51. THOMCO EMS SAFETY NET SEMINAR, 2007 Patient and Provider Safety Together (PaPST) Integrating optimal patient care with optimal provider safety. Preplanning ALS & BLS activities to occur during ‘natural’ lulls in call time. Performing ALS skills early in the time sequence of a call when the provider is already out of the vehicle. Engineering the vehicle interior so that routinely used equipment is safely within restrained reach of the provider.

52. THOMCO EMS SAFETY NET SEMINAR, 2007 PaPST Crucial Equipment Secured & Within Reach of a Restrained Provider Infusion Pumps Checked at Originating Facility IV Access Prior to Transport Airway Accessed Prior to Transport Provider Safety +?Patient Safety +?Task

53. THOMCO EMS SAFETY NET SEMINAR, 2007 PaPST Even if harnesses are effective, there are costs to upgrade a fleet. New technology diffuses slowly and every day we wait translates into additional injures and deaths. We start by retraining providers in methods of managing the call environment (e.g., continuing education). We establish policies and monitoring practices. Ultimately, we incorporate PaPST-like concepts into our training curricula.

54. THOMCO EMS SAFETY NET SEMINAR, 2007 References Available Upon Request

55. THOMCO EMS SAFETY NET SEMINAR, 2007 Coming Soon! In late May….

56. Thank You!!

57. THOMCO EMS SAFETY NET SEMINAR, 2007